International Journal of Eating Disorders

Published by Wiley
Online ISSN: 1098-108X
Print ISSN: 0276-3478
Effects of acute food deprivation on eating behavior in bulimic patients and controls were investigated. It was predicted that food deprivation would increase overall food intake and result in overeating in bulimics. Following 19 hr of food deprivation (in which breakfast and lunch were skipped), or no deprivation, food intake was measured in 9 inpatients with anorexia nervosa (binge eating/purging subtype, ANB), 10 inpatient (BN/in) and 9 outpatient (BN/out) normal-weight bulimics, and 11 unrestrained and 10 restrained controls. A general trend for increased food intake following deprivation was found. However, only BN/in patients consumed significantly more and selected higher energy foods following deprivation. ANB patients demonstrated the greatest degree of variability in intake and the least magnitude of change in ratings as a function of eating. A period of acute food deprivation did not trigger marked eating pathology as evidenced by overconsumption. Chronic dietary restraint may be a more potent precipitating factor in overeating than absolute number of hours of food restriction.
Comparison of mean (of the 2 days of the study) baseline clinical variables and self-assessed mood ratings
Comparison of mean (of the 2 days of the study) reductions in TRP and the TRP/LNAA ratio
Recent studies have raised the question as to whether a dysregulation of the neurotransmitter serotonin may contribute to the alterations in mood seen in anorexia nervosa (AN). People with AN tend to be anxious, obsessional, perfectionistic, and harm avoidant. These traits are premorbid and persist after recovery. It has been suggested that increased activity of brain serotonin systems could contribute to this pathologic condition. Dieting in AN, which serves to reduce plasma levels of tryptophan (TRP), may serve to reduce symptoms of dysphoric mood. Fourteen women currently symptomatic with AN (ILL AN), 14 women recovered from AN (REC AN), and 15 healthy control women (CW) underwent acute tryptophan depletion (ATD). Measures of psychological state were self-assessed at baseline and hourly after ATD to determine whether ATD would reduce negative mood. ILL AN and REC AN had significantly higher mean baseline TRP/LNAA (tryptophan/large neutral amino acids) ratios compared with CW. In contrast to placebo, the ATD challenge demonstrated a significantly greater reduction in the TRP/LNAA ratio for ILL AN (-95%) and REC AN (-84%) compared with CW (-70 %). Both the ILL AN and REC AN had a significant reduction in anxiety on the ATD day compared with the placebo day. These data demonstrate that a dietary-induced reduction of TRP, the precursor of serotonin, is associated with decreased anxiety in people with AN. Restricting dietary intake may represent a mechanism through which individuals with AN modulate a dysphoric mood.
Excessive exercise is present in 40%-80% of anorexia nervosa (AN) patients. Hyperactivity often plays a role in developing and maintaining AN and represents an obstacle to weight gain in refeeding. Interconnections among caloric restriction, psychopathology, and physical activity in humans with AN are poorly investigated. Physical activity and food restriction during the last 3 months and status of body image/slimness ideal were assessed by the Structured Interview of Anorexia and Bulimia Nervosa (SIAB) in 30 adolescent patients with acute AN at admission to inpatient treatment. Anxiety, depression, and obsessive-compulsiveness were assessed with the Symptom Check-List-90-Revised (SCL-90-R). A regression model based on the independent variables body mass index, food reduction, body image/slimness ideal, anxiety, depression, and obsessive-compulsiveness was calculated to determine the relevant prediction variables of physical activity. The regression model explained 64% (R(2) = .64, p = .000) of the variance of physical activity. Only food restriction (p = .006) and anxiety (p = .004) contributed significantly to the variance. Our results indicate that anxiety symptoms and food restriction synergistically contribute to increased levels of physical activity in the acute phase of AN.
A 16-year-old girl was admitted to the emergency department because of acute changes in mental state such as paranoid and nihilistic delusions, confabulations, and distortions of body schema perception. Her history was compatible with anorexia nervosa in that she had lost more than 17 kg in weight over one and a half years. Her body mass index was 14. She was diagnosed with Wernicke Korsakoff's syndrome and was given intravenous thiamine at 250 mg/day. Response was dramatic for nystagmus and gait incoordination but not for other symptoms. After dosage was increased to 750 mg/day all symptoms including psychosis improved. With her increase in food consumption, secondary deterioration was observed and diagnosed as refeeding syndrome. After proper replacements she was completely normal in the 9th month, and her weight was 55 kg. This patient was interesting for the presenting symptoms (psychosis), and improvement by high doses of thiamine replacement, and also for refeeding syndrome during this period.
To examine changes in plasma leptin levels and resting energy expenditure (REE) during short-term refeeding of patients with anorexia nervosa (AN). This was a longitudinal study of 21 women meeting the DSM-IV criteria for AN who were admitted to the hospital for renutrition. Height, weight, percent body fat (assessed by skin fold thickness), REE (measured by indirect calorimetry), and circulating plasma leptin concentration were assessed at the time of admission and 7 days later. Over the course of 1 week of refeeding, body mass index (BMI) increased 0.75 +/- 0.15 kg/m(2) (p <.0001), body fat increased 0.9 +/- 0.2% (p <.0001), and REE increased 107 +/- 33 kcal/24 hr (p =.0037). The change in mean leptin levels was not statistically significant (0.45 +/- 0.44 ng/ml; p =.32). Leptin is unlikely responsible for the increase in REE observed with short-term refeeding.
The relationship between liver damage and subsequent hypophosphatemia in malnourished patients will be discussed. The authors report two malnourished females who developed severe liver damage and subsequent hypophosphatemia. Liver damage commenced suddenly after over a week of hospitalization and deteriorated rapidly. Although the precise pathology of the liver damage could not be determined and the specific cause was not identified, steatohepatitis associated with fatty liver might be considered. Hypophosphatemia following liver damage was considered to be the result of hepatocyte regeneration and replacement of phosphorus was an effective treatment. Hypophosphatemia in these cases suggested improvement from liver damage; however, it is commonly known that hypophosphatemia has a central role in refeeding syndrome in malnourished patients. Therefore, it was concluded that attention should be paid to hypophosphatemia after liver damage.
A case of acute myocardial infarction (AMI) in a patient with anorexia nervosa is presented. Clinlcal records, electrocardiogram, echocardiogram and coronary angiogram data of a patient with anorexia nervosa, presenting with AMI were evaluated. A Pubmed literature search was used to review cardiac complications of anorexia nervosa. The patient presented with an anterior ST elevation AMI. She underwent emergent coronary angiography with successful reperfusion of a 100% occluded proximal left anterior descending coronary artery. Anorexia nervosa is an eatlng disorder affectlng mainly female adolescents. Eating disorders carry the highest mortality rate compared to other psychiatric conditions (Caslero and Frishman, Cardiol Rev 14, 227-231, 2006). It is reported that 80% of patients with an eating disorder are affected by a cardiac complication. Sudden cardiac death secondary to arrhythmia is often the cause of death in these patlents (Caslero and Frishman, Cardiol Rev 14, 227-231, 2006). AMI is rarely described as a cardiac presentation in this patient population.
A systematic epidemiological comparison of body weights of patients with anorexia nervosa can be enhanced by the use of age percentiles for the body mass index. To demonstrate the feasibility of this approach, body mass indices of 81 female adolescents with anorexia nervosa were calculated from anthropometric data upon admission for inpatient treatment and at follow-up and set into relationship to the age-dependent distribution of the body mass index in a large and representative sample of the German population. The percentiles were used to visualize the weight increase over time of each former patient by aligning the body mass index at referral with the respective body mass index at follow-up. Upon admission most adolescents had body mass indices below the third age centile. The distribution of body mass indices at outcome suggests a continuum between death of complications related to starvation, chronic anorexia, residual anorexia, and a low body weight Patients with very low body weights at referral had a poor prognosis, because their body weights tended to remain below the minimal normal weight for height. These conditions were statistically best described by categorical analysis, because they were nonlinear to a certain extent. The results indicate that the body mass index at referral influences the amount of weight that an individual patient gains in the future.
We report a case of a 26-year-old White woman with a history of anorexia nervosa who developed severe liver damage and multiorgan dysfunction. At admission to our medical unit, her body mass index (BMI) was 10.8. Biochemical evaluation showed a marked increase in serum levels of aspartate aminotransferases (AST = 9,980 IU/L), alanine aminotransferase (ALT = 3,930 IU/L), amylase (1,002 IU/L), lipase (1,437 IU/L), creatine phosphokinase (CPK; 783 IU/L), and lactate dehydrogenase (LDH = 6,830 IU/L). Glomerular filtration rate was reduced (35 ml/min), reflecting dehydration and prerenal azotemia. No other cause of acute liver damage except malnutrition was evidenced. Hydration and nutritional support were the unique medical treatment. A rapid recovery occurred in few days and all laboratory data were normal at discharge after a 37-day hospitalization.
To investigate the effects of acute alcohol intoxication on eating-related urges among women with bulimia nervosa (BN). Participants included women with BN or normal-weight eating disorder NOS with regular binge/purge symptoms (N = 13), and normal-eater control women (N = 17). Tested individually, the women reported on their mood state as well as on urges to binge eat and engage in various compensatory behaviors, prior to consuming alcohol, and again at 60 and 180 min following the consumption of 1.0 ml kg(-1) alcohol. Both groups reported feeling less clearheaded after drinking, as well as initial subjective mood stimulation followed by subsequent mood lowering. In addition, BN participants reported reductions in their urges to binge eat, exercise compulsively, and restrict food intake following alcohol consumption-the urge to purge was not significantly affected. Among women with BN, alcohol consumption appeared to reduce select eating-related urges with concomitant reductions in attention or concentration.
Acute gastric dilatation (AGD) is a very rare entity which can sometimes be life-threatening. We report a case of a patient presenting with a rupture of a BCA during the treatment of AGD. A 24-year-old woman, who had a history of bulimia and vomiting episodes, was transferred in shock with marked abdominal distension. A large nasogastric tube was inserted, and 9 liters of viscous gastric contents were drained out. Her circulation became stable. About 3 months after admission, she became drowsy and presented with a right hemiparesis and aphasia. Computed tomography of the head showed a diffuse thick subarachnoid hemorrhage. Left carotid angiograms revealed an obscurely-shaped aneurysm in the left middle cerebral artery. Trapping of the aneurysm was performed. Thirty-four days after admission, the patient had a residual right hemiparesis and motor aphasia, and was discharged.
Anorexia nervosa (AN) is an eating disorder predominantly affecting young women. Abnormal liver function tests (LFT's) resulting from AN is well-described but to date few cases of dramatic rises in liver enzymes have been described. We report a 32-year-old women with severe anorexia having dramatic rise in LFT's with liver failure during extremely poor nutritional status. Acute rise in liver enzymes observed on several occasions in this patient resulted from ischaemic hepatitis secondary to liver hypoperfusion. Clinicians caring for patients with severe AN should monitor haemodynamic parameters with the knowledge that acute liver failure can be a consequence of sudden liver hypoperfusion. Therapeutic intervention comprising volume support with gradual nutritional support results in normalization of LFT's.
To illustrate the close association between a disturbed psychosocial up-bringing, frequent physical illness, and medical interventions. We report a case of a 44-year-old woman with anorexia nervosa (AN) and Sheehan's syndrome who died as a result of a toxic cardiac arrest. The patient presented with a BMI of 13.6 kg/m(2). She refused any intensive-care treatment and died from toxic cardiac arrest. Postmortem examination revealed an acute gastroenterocolitis. The history of this patient illustrates how psychological deprivation led to eating disturbances, early pregnancy, and the life-threatening delivery of twins. This resulted in a diagnosis of Sheehan's syndrome, hepatitis C, and a ventricular ulcer. A psychosocial event triggered a late exacerbation of her AN. A helpful alliance between patient and staff did not occur as she rejected it.
A 22-year-old woman is presented with acute gastric dilation after an eating binge, who died of complications of acute reperfusion syndrome. A young patient was admitted in our clinic with critical condition without any significant previous medical history. Her initial complaints--diarrhea, vomiting and abdominal pain--began after an enormous food intake. There was no history of medications or toxic substances. Physical examination showed a normally-developed, well-nourished female in severe distress with an extremely distended abdomen. Femoral pulses were absent. The US and CT scan showed a dilated stomach, extended into the pelvis, dislocating the intestinal organs and compressed the aorta and mesenteric veins. Urgent laparotomy was performed. An enormously distended stomach was encountered without volvulus, obstruction or adhesions. About 11 liters of gastric content was removed gastrotomy and nasogastric tube. Following the gastric decompression, the mesenteric and femoral pulses reappeared. During the operation, the cardio-respiratory status was stabilized, but in the following 24 hours irreversible shock developed, possibly due to the reperfusion of the retroperitoneal organs and the lower extremities. In the postoperative period disseminated intravascular coagulopathy developed. In an uncontrollable state of diffuse bleeding, 36 hours post-operation, the patient died. In retrospective investigation, the family confessed that previous psychological treatments which aimed at her bulimic attacks. Acute gastric dilatation is very uncommon and is of various etiologies, two of these being anorexia nervosa and bulimia. Several cases documenting complications of gastric dilatation were published; however, such severe complications, involving gastric infarction and compression of the aorta with ischemic injury of the bowels and lower extremities, are rare.
Because little is known about energy requirements in anorectic patients before and after weight gain we measured resting metabolic rate (RMR) by indirect calorimetry and total energy expenditure (TEE) by the doubly labeled water method in 6 patients with anorexia nervosa (body mass index [BMI] = 15.1 +/- 1.3 kg/m2), in 6 weight-recovered anorectics (BMI = 21.2 +/- 2.1 kg/m2), and in 12 healthy age-matched women (BMI = 20.5 +/- 1.9 kg/m2). No significant differences were found between the weight-recovered anorectic women and the healthy controls in RMR (1,330 +/- 131 kcal/day [weight-recovered]; 1,419 +/- 197 [controls]) and in TEE (2,602 +/- 637 kcal/day [weight-recovered]; 2,596 +/- 493 kcal/day [controls]). The RMR was significantly lower in the acutely ill anorectic patients (1,171 +/- 113 kcal/24 hr) than in weight-recovered anorectics and in healthy controls. The TEE was significantly lower in the anorectic group (1,946 +/- 192 kcal/day) than in the healthy controls.
t-tests comparing CIA scores in symptomatic versus asymptomatic groups on nine indices of eating disorder psychopathology.  
Correlations between CIA and continuous measures of eating disorder psychopathology and measures of generalized psychopathology and distress evaluating construct validity in an ethnic Fijian sample
Measurement of disease-related impairment and distress is central to diagnostic, therapeutic, and health policy considerations for eating disorders across diverse populations. This study evaluates psychometric properties of a translated and adapted version of the Clinical Impairment Assessment (CIA) in an ethnic Fijian population. The adapted CIA was administered to ethnic Fijian adolescent schoolgirls (N = 215). We calculated Cronbach's alpha to assess the internal consistency, examined the association between indicators of eating disorder symptom severity and the CIA to assess construct and criterion validity, and compared the strength of relation between the CIA and measures of disordered eating versus with measures of generalized distress. The Fijian version of the CIA is feasible to administer as an investigator-based interview. It has excellent internal consistency (alpha = 0.93). Both construct and criterion validity were supported by the data, and regression models indicated that the CIA predicts eating disorder severity, even when controlling for generalized distress and psychopathology. The adapted CIA has excellent psychometric properties in this Fijian study population. Findings suggest that the CIA can be successfully adapted for use in a non-Western study population and that at least some associated distress and impairment transcends cultural differences.
Loadings on each of the four factors derived from an exploratory factor analysis of the EDE-Q in an ethnic Fijian population. 
Internal consistency and test-retest reliability for continuous and categorical items for participants who completed English or Fijian language versions of the EDE-Q English Fijian Continuous Items Time 1 Cronbach's a (n 5 140-146) a Test-Retest ICC (n 5 21) Time 1 Cronbach's a (n 5 360-374) a Test-Retest ICC (n 5 60) 
Inter-correlations among factors in EDE-Q factor analysis 
Assessment of disordered eating has uncertain validity across culturally diverse populations. This study evaluated Eating Disorder Examination Questionnaire (EDE-Q) performance in an ethnic Fijian study population. The EDE-Q was translated, adapted, and administered to school-going Fijian adolescent females (N = 523). A subsample (n = 81) completed it again within approximately 1 week. We assessed feasibility, internal consistency, and test-retest reliability; evaluated construct validity through factor analysis and correlation with similar constructs; and examined the marginal utility of an additional question on traditional purgative use. Internal consistency reliability was adequate for the global scale and subscales (Cronbach's alpha = 0.66-0.91); retest reliability was adequate for both the languages (range of ICCs, 0.50-0.79, and of kappas, 0.46-0.81, excluding purging items). Construct validity was supported by significant correlations with measures of similar constructs. Factor analysis confirms multiple dimensions of eating disorder symptoms but suggests possible culture-specific variation in this population. The majority of respondents endorsing traditional purgative use (58%) did not endorse conventional EDE-Q items assessing purging. The EDE-Q is a valid measure of eating disorder pathology for ethnic Fijian adolescent females and measures a unitary underlying construct.
Severe hypokalemia may constitute a life-threatening medical emergency. In the group of purging eating disorder patients, potassium blood levels tend to be chronically low while physical signs and symptoms may be absent. Nevertheless, these patients are frequently subjected to vigorous supportive treatment and often an aggressive diagnostic workup. We present a chronic purging anorexia nervosa patient in whom potassium blood levels reach a low of 1.6 mmol/L in the absence of physical symptoms. Purging eating disorder patients adapt to chronic hypokalemia. We believe the clinical/medical approach to this electrolyte disturbance in chronic eating disorder patients should be different from the approach to patients suffering from acute hypokalemia.
We evaluated several indices of pretreatment social adaptation (social and vocational adjustment, DSM-III-R Axis-V ratings, and "object-relations" capacities) as predictors of the response of 44 completers of a multimodal therapy for bulimia nervosa. Response was assessed using standard measures of eating and psychiatric symptoms. Hierarchical regressions revealed that pretreatment social adjustment explained substantial (and significant) proportions of variance in posttreatment binge/purge symptoms, after variance associated with (a) initial severity of eating symptoms and (b) concurrent psychiatric symptoms (at posttreatment) was accounted for. Hence, social adjustment emerged as a somewhat specific predictor of response of bulimic behaviors. Possible clinical implications of this apparent predictive effect are discussed.
Patients with eating disorders were asked to color-name pictures of a variety of body shapes. The time taken to color-name these stimuli was compared with the time taken to color-name a series of neutral visual stimuli. There was a significant delay in naming body shapes in comparison to neutral stimuli, and this delay was greater in anorexic and bulimic patients than in controls. Previous Stroop adaptations have used verbal stimuli to assess the intensity of weight and shape-related concerns. The possible advantages of pictorial stimuli are discussed.
Eating in response to negative emotions is associated with binge or loss of control (LOC) eating in adults. Although children report engaging in LOC eating, data on emotional eating among youth are limited. We adapted the adult Emotional Eating Scale (Arnow et al., Int J Eat Disord, 18, 79-90, 1995) to be used with children and adolescents (EES-C). Fifty-nine overweight (BMI > or = 95th percentile for age and sex) and 100 non-overweight (BMI 5th-94th percentile) participants (mean age +/- SD 14.3 +/- 2.4 years) completed the EES-C, and measures of recent LOC eating and general psychopathology. Test-retest reliability was assessed in 64 children over a 3.4 +/- 2.6 month interval. A factor analysis generated three subscales: eating in response to anxiety, anger, and frustration (EES-C-AAF), depressive symptoms (EES-C-DEP), and feeling unsettled (EES-C-UNS). Internal consistency for the subscales was established; Cronbach's alphas for the EES-C-AAF, EES-C-DEP, and EES-C-UNS were 0.95, 0.92, and 0.83, respectively. The EES-C had good convergent validity: children reporting recent LOC eating episodes scored higher on all subscales (p's < 0.05). The EES-C-AAF and EES-C-UNS subscales demonstrated good discriminant validity and the EES-C-DEP revealed adequate discriminant validity. Intra-class correlation coefficients revealed good temporal stability for each subscale (EES-C-AAF = 0.59, EES-C-DEP = 0.74, EES-C-UNS = 0.66; p's < 0.001). The EES-C has good convergent and discriminant validity, and test-retest reliability for assessing emotional eating in children. Further investigation is required to clarify the role emotional eating may play in children's energy intake and body weight.
This case study describes a skills training treatment for binge eating which focused on teaching adaptive affect regulation. A 36-year-old obese woman with a long history of severe binge eating received individual treatment specifically aimed at enhancing her emotion regulation abilities. By treatment end she no longer met criteria for binge eating disorder.
To examine prevalence and correlates (gender, Body Mass Index) of disordered eating in American Indian/Native American (AI/NA) and white young adults. We examined data from the 10,334 participants (mean age 21.93 years, SD = 1.8) of the National Longitudinal Study of Adolescent Health (ADD Health) Wave III for gender differences among AI/NA participants (236 women, 253 men) and ethnic group differences on measures of eating pathology. Among AI/NA groups, women were significantly more likely than men to report loss of control and embarrassment due to overeating. In gender-stratified analyses, a significantly higher prevalence of AI/NA women reported disordered eating behaviors compared with white women; there were no between group differences in prevalence for breakfast skipping or having been diagnosed with an eating disorder. Among men, disordered eating behaviors were uncommon and no comparison was statistically significant. Our study offers a first glimpse into the problem of eating pathology among AI/NA individuals. Gender differences among AI/NA participants are similar to results reported in white samples. That AI/NA women were as likely as white women to have been diagnosed with an eating disorder is striking in light of well documented under-utilization of mental health care among AI/NA individuals.
This study examined the psychometric properties of the Yale food addiction scale (YFAS) in obese patients with binge eating disorder (BED) and explored its association with measures of eating disorder and associated psychopathology. Eighty-one obese treatment-seeking BED patients were given the YFAS, structured interviews to assess psychiatric disorders and eating disorder psychopathology, and other pathology measures. Confirmatory factor analysis revealed a one-factor solution with an excellent fit. Classification of "food addiction" was met by 57% of BED patients. Patients classified as meeting YFAS "food addiction" criteria had significantly higher levels of depression, negative affect, emotion dysregulation, eating disorder psychopathology, and lower self-esteem. YFAS scores were also significant predictors of binge eating frequency above and beyond other measures. The subset of BED patients classified as having YFAS "food addiction" appear to represent a more disturbed variant characterized by greater eating disorder psychopathology and associated pathology.
Two studies are presented, which examine cue reactivity in dieting. Experiment 1 investigated whether the presence of a preferred food affected dieters' performance on measures of attention, reaction time, and motor speed. The manipulation did not affect the performance. Experiment 2 investigated the performance of dieters (N = 19), highly restrained non-dieters (N = 18) and low-to-medium restrained eaters (N = 34) on two simple reaction time tasks. Subjects were either required to imagine their favorite food or to imagine their favorite holiday while completing a reaction time task. In the food condition, both dieters and restrained nondieters displayed significantly slower reaction times during the first three of five blocks of the task than the low-to-medium restrained eaters. The results are discussed in terms of Tiffany's (Psychological Review 97:147-168, 1990) model of cue reactivity in that different abstinent states produce comparable effects upon performance.
The present study examined whether additional sessions of group psychotherapy process (PP) would incrementally benefit bulimia nervosa (BN) subjects over and above that which is achieved through a course of brief group psychoeducation (PE). Utilizing a quasi-experimental design, the first cohort of 40 BN subjects completed five-session PE-alone groups that were highly didactic and explicitly devoid of group process work. The second cohort of 41 BN subjects completed 12-session PE + PP groups that integrated PE with more conventional cognitive-behavioral group process interventions. Both treatments were associated with comparable levels of change on measures of specific and nonspecific psychopathology. Furthermore, the two treatments did not differ in rates of premature termination, in rates of remission in eating symptoms, in rates of normalization of scores on psychometric measures, or in consumer evaluation of the treatments. While subjects value the opportunity to engage in psychotherapy process with other group members, the addition of seven such sessions offers no enhanced therapeutic benefit over five sessions of group PE.
Although some research suggests that online eating disorder forums promote "pro-eating-disorder" lifestyles and discourage recovery, other research suggests that such forums are an important source of interpersonal support. The current study extends this research by exploring the positive and negative behaviors encouraged on these forums and by comparing forum members' perceptions of support received from online and offline relationships to support received in relationships of age-matched controls. In a survey of 60 forum members, we assessed information exchanged and support provided on eating disorder forums. Further, we assessed perceptions of social support for general and specific life concerns in this group of forum members as well as 64 age-matched university controls. Results show that both adaptive and maladaptive behaviors are encouraged on the forums, and that this encouragement has some influence on forum members trying out these behaviors. Overall, forum members reported receiving less support for their eating concerns as compared to their general life stressors, and they perceived less support for both their general concerns and eating concerns in their offline relationships as compared to their online forum relationships. Moreover, forum members reported receiving less support from their offline relationships as compared to support received in relationships by age-matched controls. Forum members perceive less support in their important relationships than other peers do, and they seek out and participate in forums as a means of attaining greater social support. However, our research suggests that these forums also encourage dysregulated eating behaviors. Implications of online forum support and its impact on recovery are discussed further.
Despite data linking Attention-deficit/Hyperactivity Disorder (ADHD) and adult binge eating, there are limited data in children with loss of control (LOC) eating. We examined inhibitory control in children with LOC eating syndrome (LOC-ES) and its association with ADHD. 79 children (8-14 years) over the fifth weight percentile were recruited, irrespective of LOC eating or ADHD status. The Eating Disorder Examination for Children and the Standard Pediatric Eating Episode Interview assessed LOC-ES. ADHD diagnosis was determined by the Schedule for Affective Disorders and Schizophrenia for children and Conners-3 (Parent Report) DSM-IV Scales of Inattention and/or Hyperactivity (T score>65). The Go/No-Go (GNG) Task and the Behavior Regulation Inventory of Executive Function (BRIEF) assessed impulse control. Odds of LOC-ES were increased 12 times for children with ADHD (adjusted odds ratio [aOR] = 12.68, 95% confidence interval [CI] = 3.11, 51.64, p < 0.001), after adjusting for BMI z scores and relevant covariates. Children had 1.17 times higher odds of reporting LOC-ES with every 5% increase in GNG Commission Rate (aOR = 1.17, CI = 1.01, 1.36, p < 0.05) and 1.25 times higher odds of reporting LOC-ES with every 5 unit T-score increase in BRIEF Inhibit Scale (aOR = 1.25, CI = 1.04, 1.50, p < 0.05). Children with ADHD had significantly greater odds of LOC-ES compared to children without ADHD. Children with LOC-ES had significantly greater impulse control deficits on performance-based neuropsychological assessments and on parent reports than children without LOC-ES. These findings suggest a need to investigate possible shared mechanisms such as impulse control deficits, among children with LOC-ES and ADHD. © 2015 Wiley Periodicals, Inc (Int J Eat Disord 2015). © 2015 Wiley Periodicals, Inc.
We investigated body image dissatisfaction and bingeing/purging characteristics of bulimia nervosa (BN) in the ongoing prospective follow-up of the Multimodal Treatment Study of Children with attention-deficit/hyperactivity disorder (ADHD). Participants were 337 boys and 95 girls with ADHD and 211 boys and 53 girls forming a local normative comparison group (LNCG), reassessed in midadolescence (mean age, 16.4), 8 years after original recruitment. Youth with childhood ADHD showed more BN symptoms in midadolescence than did LNCG youth, and girls demonstrated more BN symptoms than did boys, with effect sizes between small and medium. Childhood impulsivity, as opposed to hyperactivity or inattention, best predicted adolescent BN symptoms, particularly for girls. Among youth with ADHD, treatment received during the follow-up period was not associated with BN pathology. Both boys and girls with ADHD may be at risk for BN symptoms in adolescence because of the impulsivity central to both disorders.
There is increasing literature suggesting a link between attention-deficit hyperactivity disorder (ADHD) and eating disorders (EDs), especially bulimia nervosa. ADHD is under-diagnosed in girls and children of high intelligence are typically missed. We identified a case of a 23-year-old woman suffering from severe bulimia nervosa and previously unsuspected ADHD in adulthood; we diagnosed and treated her with extended-release methylphenidate. We performed a literature review on the ADHD and bulimia nervosa comorbidity. We discuss the reasons why her ADHD remained undiagnosed and the difficulties in diagnosing ADHD in patients with EDs. We suggest that identifying comorbid ADHD is crucial for these patients and argue for the use of a structured interview, collateral history and investigation of onset of symptoms to establish a diagnosis of ADHD in adults with bulimia nervosa. Comorbidities and overlap of symptomatology need to be taken into account. © 2013 Wiley Periodicals, Inc. (Int J Eat Disord 2013).
Starvation-induced depletion of fat stores in anorexia nervosa (AN) is known to be accompanied by alterations in some circulating adipocytokines. We analyzed a panel of circulating adipocytokines in women with AN compared with normal-weight controls and their relation with the disease duration and weight restoration. We analyzed circulating adipocytokine levels in 28 patients with AN and in 33 normal-weight controls who were eating healthily. We determined by enzyme-linked immunosorbent assay the circulating levels of total and high molecular weight (HMW) adiponectin, lipocalin-2 (LCN2), leptin, tumor necrosis factor receptor-II (TNFRII), interleukin-6 (IL6), adipocyte fatty acid binding protein-4 (FABP4), ghrelin, and resistin. The two circulating forms of adiponectin are higher in AN women compared with controls. Both total and HMW adiponectin related negatively to the duration of the disease (r = -0.372, p = 0.033; r = -0.450, p = 0.038, respectively). Furthermore, the lipid binding-proteins LCN2 and FABP4 are lower in AN compared to the control group. Finally, leptin levels are lower in AN against controls and correlated positively with disease duration (r = 0.537, p = 0.007). Resistin, ghrelin, TNFRII, and IL6 have similar values in both groups, although TNFRII and ghrelin related negatively to body mass index variation at the end of treatment (r = -0.456, p = 0.039; r = -0.536, p = 0.015, respectively). These results suggest there is a need to investigate if changes in adipocytokine levels could serve as weight restoration biomarkers. Further studies are warranted to elucidate the specific role of these molecules in the timing of weight restoration. © 2013 Wiley Periodicals, Inc. (Int J Eat Disord 2013).
To investigate the relationship between loss of control over eating, adiposity, and psychological distress in a nontreatment sample of overweight children. Based on self-reports of eating episodes, 112 overweight children, 6-10 years old, were categorized using the Questionnaire of Eating and Weight Patterns-Adolescent Version into those describing episodes of loss of control over eating (LC), and those with no loss of control (NoLC). Groups were compared on measures of adiposity, dieting, and eating behavior, and associated psychological distress. LC children (33.1%) were heavier and had greater amounts of body fat than NoLC children. They also had higher anxiety, more depressive symptoms, and more body dissatisfaction. 5.3% met questionnaire criteria for BED. Episodes of loss of control occurred infrequently, were often contextual, and involved usual meal foods. As in adults, overweight children reporting loss of control over eating have greater severity of obesity and more psychological distress than those with no such symptoms. It remains unknown whether children who endorse loss of control over eating before adolescence will be those who develop the greatest difficulties with binge eating or obesity in adulthood.
This open clinical trial examined the efficacy of treating obese patients with binge eating disorder (BED) with phentermine and fluoxetine in the setting of cognitive-behavioral therapy (CBT). Sixteen obese women received individual CBT along with phentermine/fluoxetine. Treatment goals included elimination of binge eating, weight loss, and reduced psychological distress. Following active treatment, patients were offered once-monthly maintenance treatment for 3 years. Patients showed significant reduction in binge frequency, weight loss, and psychological distress at the end of active treatment, but regained most of the weight within 1 year. At 18-month follow-up, there was an ongoing reduction in binge eating for patients who continued maintenance. Treatment produced comparable binge suppression and more weight loss than most reported studies of CBT alone. However, there is significant weight regain, particularly following medication discontinuation. This study does not support the long-term clinical utility of adding phentermine/fluoxetine to CBT for BED.
A recent case report suggested that olanzapine resulted in improved weight gain and maintenance, as well as decreased anxiety and agitation, for two hospitalized inpatients with anorexia nervosa (AN). However, a subsequent larger case study did not show a relationship between the use of olanzapine and rate of weight gain among a primarily adult population. The aim of this case report was to clinically examine the therapeutic benefit and tolerability of olanzapine as an adjunctive treatment for four children with AN in a pediatric inpatient setting. Olanzapine use was associated with considerable weight gain and maintenance, with an average rate of weight gain during hospitalization of 0.99 kg per week. In addition to weight gain, olanzapine was associated with a clinically notable decrease in levels of agitation and premeal anxiety and almost immediate improvement in sleep, general functioning, and overall compliance with treatment. Olanzapine was also well tolerated in these young patients. These case report findings warrant more controlled research, including randomized controlled studies, to better determine the therapeutic benefits and safety of olanzapine use in children with AN.
To evaluate the effectiveness of haloperidoll as an adjunctive treatment for resistant anorexia nervosa restricting subtype (AN-R). Thirteen outpatients with treatment-resistant AN-R were treated for 6 months with haloperidol in addition to standard treatment. Treatment resistance was defined as persistent and resistant anorectic symptoms despite multiple standard therapies. Assessments were carried out at baseline and after 1, 3, and 6 months with the Eating Disorder Inventory (EAT), the Eating Attitude Test (EAT), and the Clinical Global Impression and Improvement Scale (CGI-I). Significant change from baseline to end point was observed on EDI total score (p =.02) and on the subscales Drive for Thinness (p =.009), Bulimia (p =.01), and Interoceptive Awareness (p =.02), as well as on the EAT (p =.009) and CGI scores (p =.001). Body mass index changed significantly from baseline (15.7 +/- 1.9) to end point (18.1 +/- 2.5; p =.03). These preliminary data suggest that low doses of haloperidol might be effective as an adjunctive treatment for patients with severe AN-R. Larger controlled studies are warranted to confirm these data.
To examine recovery status in bulimia nervosa (BN) and its relation to social support and social adjustment. Using a cross-sectional design, we administered the modified Social Support Questionnaire and the Social Adjustment Scale-Self-Report (SAS-SR) to 40 women, each of whom was actively bulimic (ABN), was in remission from BN (RBN), or had no history of eating disturbance (comparison). In terms of social support, relative to RBN and comparison subjects, the ABN group had significantly fewer persons in their friendship and kinship networks available to provide emotional support, although the groups were equivalent in number of persons available to provide things and advice. Relative to the comparison group, both bulimic groups were significantly dissatisfied with the quality of emotional support provided by relatives. On the SAS-SR, women in the ABN group displayed the poorest overall social functioning. The RBN group was functioning significantly better than the ABN group, but significantly more poorly than the comparison group. Our results suggest that the social functioning of RBN women lies between ABN women and non-eating-disordered women, indicating both gains relative to the active phase and residual deficits.
To study early adaptation to motherhood in mothers with eating disorders (ED) before pregnancy. Forty-four nulliparous nonsmoking women with ED before pregnancy (24 anorexia nervosa, 20 bulimia nervosa) and 67 controls were recruited from the same prenatal clinics. Three months after delivery, the women completed the maternal adjustment and maternal attitude questionnaire (MAMA) and were asked about mental health problems postpartum. Ninety-two percent of mothers with ED before pregnancy reported problems regarding their maternal adjustment compared to 13% in the control group (p < 0.001), whereas there were no differences between the subgroups of ED and between those with and without verified relapse of ED during pregnancy. Fifty percent of mothers with previous ED reported that they had been in contact with health services after delivery because of depression or other mental problems and these women had significantly higher MAMA score than patients not reporting such contact with health services (p < 0.001). Adjustment to motherhood was clearly impaired and related to mental problems in mothers with ED before pregnancy.
The authors sought to describe social adjustment among women diagnosed with bulimia nervosa more than a decade earlier. A cohort of women who were diagnosed with bulimia nervosa between 1981 and 1987 were located and invited to participate in follow-up assessments. Although the current sample demonstrated considerable improvement in disordered eating behaviors and social adjustment, measures of social adjustment suggested continued impairment in interpersonal relationships and only a modest association with eating disorder outcome. Continued difficulties in social adjustment may reflect an underlying vulnerability from which disordered eating developed. Treatments for bulimia nervosa may benefit from including interpersonal skills training.
To examine a structural equation model of the effects of personal and interpersonal factors on treatment outcome of bariatric surgery and weight-loss program. Forty-four participants of the surgery group and 47 participants of the diet group completed questionnaires before treatment and 1 year afterward. Predictor measures are as follows: social support, motivation for control, sense of control, self-esteem, neuroticism, fear of intimacy, and emotional eating (EE). Weight loss, quality of life, and mental health. Neurotic predisposition (NP), a latent variable indicated by neuroticism, low self-esteem, and fear of intimacy, had an effect on weight loss that was fully mediated by EE. NP also had an effect on quality of life improvement that was fully mediated by EE and weight loss in both treatment groups. Both NP and EE predict outcome of obesity treatments, but EE is the more proximal variable that mediates the effect of NP.
To analyze the relationship between family functioning and psychosocial adjustment in Dutch overweight children and adolescents. Seventy-three overweight (weight-for-height >P90) and 70 normal-weight youngsters between the ages of 10 and 16 years were recruited by school physicians during routine medical screening. The Family Dimension Scale, the Child Behavior Checklist, the Teacher Report Form, the Self-Perceived Competence Scale, and the Body-Esteem Scale were filled out, as well as a specific weight-related questionnaire. Both parents and teachers report more behavior problems in overweight children, particularly in the younger than 13 age group. Lower body-esteem was found in older overweight girls, whereas in older overweight boys higher levels of body-esteem were found. More significant relationships were found with the weight-related Parental Concern Scale than with the Family Dimension Scale. The results suggest that a developmental psychological approach reveals important age and sex differences. Weight-related instruments may be more useful than general questionnaires.
The low prevalence of restrictive eating disorders among black women has been attributed primarily to cultural differences in the definition of beauty. Utilizing self-report measures, this study examined differences in the nature of disordered eating behaviors for black and for white female college students. Analyses of covariance and correlational tests revealed that white females demonstrated significantly greater disordered eating attitudes and behaviors than black females. Additionally, the data indicated that although disordered eating behaviors and attitudes are related to actual weight problems for black females, this is not the case for white females. Furthermore, this study is the first to provide evidence that restrictive eating disorders among black women are related to the degree to which they assimilate to mainstream culture. Finally disordered eating behaviors and attitudes were related to depression, anxiety, and low self-esteem in both groups.
To develop and evaluate an instrument to assess severity in anorexia nervosa (AN), the Clinician Administered Staging Instrument for Anorexia Nervosa (CASIAN). Candidate items for the CASIAN were developed in three phases (domain, content, and item generation) followed by a pilot study. The psychometric properties of the resultant 34-item questionnaire were investigated in cross-sectional and longitudinal samples (N = 171) with DSM-IV AN and subthreshold AN. Item and factor analysis procedures resulted in a refined 23-item CASIAN comprising of six factors ("Motivation," "Weight," "Illness Duration," "Obsessionality," "Bulimic Behaviors," and "Acute Issues"). The CASIAN had high internal consistency (.811), test-retest (.957), and interrater reliability (.973). Preliminary support for the convergent, discriminant, concurrent, and predictive validity of the CASIAN was found. The CASIAN is a psychometrically sound instrument. Further studies are needed to confirm the factor structure and assess its clinical and research utility.
This report describes the therapy of 2 women with bulimia nervosa who were treated using cognitive-behavioral therapy delivered via telemedicine. The telecommunication link was established using a 128-Kbps ISDN switchable data line. Both cases were treated successfully and were doing well at 1-month follow-up. These cases illustrate that this methodology may make it possible to deliver manual-based psychotherapies to patients with eating disorders in remote areas. © 2001 by John Wiley & Sons, Inc.. Int J Eat Disord 30: 454–457, 2001.
The aim of the study was to examine how carers cope practically and emotionally with caring for individuals with anorexia nervosa who require intensive hospital care. This study explores objective burden (time spent with caregiving and number of tasks), subjective burden (psychological distress), and social support in a sample of parents (n = 224) and partners (n = 28) from a consecutive series of patients (n = 178) admitted to inpatient units within the United Kingdom. Most time was spent providing emotional support and less with practical tasks. Time spent with caregiving was associated with carer distress and was fully mediated by carer burden. This was ameliorated by social support. Partners received minimal support from others, and we found similar levels of burden and distress for mothers and partners. The data indicate that professional and social support alleviates carer distress and may be of particular value for partners who are more isolated than parents. The data also suggest that time spent with practical support may be of more value than emotional support. © 2012 by Wiley Periodicals, Inc. (Int J Eat Disord 2013;)
This work describes the developmental course of adolescents' weight concerns and examines links with changes in parent-adolescent relationships for girls and boys. Adolescents and parents in 191 families participated in 3 annual home interviews; adolescents rated their weight concerns and their intimacy and conflict with parents. Parental knowledge was measured based on the match between adolescents' and parents' reports of youth's experiences each day during 7 evening telephone calls. Girls' weight concerns increased from age 11 to 16 and then declined, whereas boys' concerns declined beginning at age 11. Increases in girls' weight concerns were linked to increases in conflict with mothers and fathers and decreases in maternal intimacy and knowledge. At a trend level, declines in boys' weight concerns were associated with declines in father conflict. Mothers and fathers may have unique influences on adolescent weight concerns. Intervention programming should target parent-adolescent relationships.
Given the frequency of transition from anorexia nervosa to bulimia nervosa, this study investigated whether a history of activity-based anorexia (ABA) during adolescence would promote binge eating during adulthood in female rats. Adolescent rats were given 1-h unlimited access to chow and ad libitum access to a running wheel until body weight reached <80%, indicating the development of ABA. During adulthood, all groups were given 21 days of access to a palatable food for 2 h/day and ad libitum access to chow. During adolescence, rats in the ABA paradigm developed increased wheel running and decreased food intake, reaching <80% of body weight after 3 days. However, there were no significant differences between groups in the amount of binge food consumed during adulthood. A brief episode of ABA during adolescence did not lead to increased binge eating later in life. Longer-term models are needed to determine whether a propensity toward binge eating may result from more sustained ABA during adolescence.
Studies of adolescent psychiatric disorders often collect information from adolescents and parents, yet most eating disorder epidemiologic studies only rely on adolescent report. We studied the eating disorder symptom reports, from questionnaires sent at participants' ages 14 and 16 years, provided by 7,968 adolescents from the Avon Longitudinal Study of Parents and Children (ALSPAC), and their parents. Adolescents and parents were asked questions about the adolescent's eating disorder symptoms (binge eating, vomiting, laxative use, fasting, and thinness). We assessed cross-sectional concordance and prevalence using kappa coefficients and generalized estimating equations. Generalized estimating equations were used to assess prospective associations between symptom reports and adolescent weight outcomes measured at a face-to-face assessment at 17.5 years. Parents and adolescents were largely discordant on symptom reports cross-sectionally (kappas < 0.3), with the parent generally less likely to report bulimic symptoms than the adolescent but more likely to report thinness. Female adolescents were more likely to report bulimic symptoms than males (e.g., two to four times more likely to report binge eating), while prevalence estimates according to parent reports of female vs. male adolescents were similar. Both informants' symptom reports were predictive of body mass and composition measures at 17.5 years; compared to adolescent report, parentally reported binge eating was more strongly predictive of body mass index. Parent report of eating disorder symptoms seemed to measure different, but potentially important, aspects of these symptoms during adolescence. Epidemiologic eating disorder studies should consider the potential value added from incorporating parental reports, particularly in studies of males. © 2014 Wiley Periodicals, Inc. (Int J Eat Disord 2014).
Early maturing girls are at increased risk for disordered eating. However, it is unclear if the association between puberty and disordered eating continues throughout pubertal development and if a similar association is exhibited in boys. Participants included 1340 same- and 624 opposite-sex twins from the Swedish Twin Study of Child and Adolescent Development. Pubertal development was assessed at age 13-14 with the pubertal development scale. General disordered eating, measured with the eating disorder inventory-2 (EDI) was assessed at age 16-17, and dieting and purging behaviors were assessed at both ages 16-17 and 19-20. We applied analysis of variance and logistic regression analyses to determine whether pubertal development in early-to-mid adolescence predicted eating disorder-related behaviors in late adolescence and young adulthood. Pubertal development in early-to-mid adolescence was significantly associated with EDI scores and dieting in late adolescence. No significant association was observed between pubertal development and dieting and purging in young adulthood. Complex combinations of cultural and biological influences likely converge during pubertal development increasing vulnerability to disordered eating. The impact of pubertal development on disordered eating appears to be limited to the adolescent period. © 2012 by Wiley Periodicals, Inc. (Int J Eat Disord 2012;45:819-826).
This cross-sectional survey study examined dieting and exercise variables as a function of parental education in 2,174 male and 1,804 female college-bound high school graduates aged 18 years. Parental education is an index of socioeconomic status (SES). Higher SES was associated with lower current and desired body weight in both women and men. The prevalence of dieting, binging, and vigorous exercise for weight control increased with SES for women but not for men. These data confirm the inverse relationship between body weight, dieting, and social class, previously demonstrated with American adults.
This is a study of prevalence rates for anorexia nervosa (AN) and bulimia nervosa (BN) in an epidemiological sample of Swiss adolescents. A two-stage approach was used which involved the screening of a large sample of adolescents aged 14-17 and subsequent interviews of screen-positive and control subjects. The prevalence rates for adolescent girls were 0.7% for AN and 0.5% for BN. Full clinical syndromes of AN and BN in adolescents are by far less frequent than individual symptoms of eating disorders. There is more cross-cultural variation for prevalence rates in BN than in AN.
Top-cited authors
Cynthia Bulik
  • University of North Carolina at Chapel Hill
Tatjana van Strien
  • Radboud University
Ross D Crosby
  • Sanford Health
Ruth Striegel Weissman
  • Wesleyan University
Janet L Treasure
  • King's College London