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[Borderline syndrome and eating disorders. Review of the literature and interview study of 172 consecutive patients of the Freiburg Eating Disorders Outpatient Clinic].

The comorbidity of personality discorders and eating discorders is an important topic of theoretical and empirical investigation in the field of eating disorders. There is disagreement both concerning the extent of such comorbidity and it's clinical implications for the development and conduct of treatments. After a critical review of the literature up to 12/1994, we report on the results of a standard screening for borderline personality disorder (BPD) with the Diagnostic Interview for Borderlines--Revised (DIB-R) administered by trained and reliable raters in a consecutive sample of 172 first attenders of a regional eating disorders clinic (anorexia, restrictive type [DSM-IV 307.1]: n = 31, anorexia, binge eating/purging type [DSM-IV 307.1]: n = 29, bulimia nervosa [DSM-IV 307.51]: n = 80, eating disorder NOS [DSM-IV 307.50]: n = 32). 8.8% of all eating disordered patients (n = 172) and 10.0% of patients fulfilling the criteria for either anorexia or bulimia (n = 140) met the criteria of a BPD (DIB-R score > or = 8). There were no significant differences between the anorectic and bulimic subgroups. BPD-patients did not differ from the non-BPD patients in the extent or type of their eating disorder. These results differ substantially from those reported in (mostly) smaller and more selected samples. Their nosological and clinical implications are discussed.

Adolescent↗

Weight-related and shape-related self-evaluation in eating-disordered and non-eating-disordered women.

OBJECTIVE: Weight- and shape-related self-evaluation refers to the process whereby an individual determines her self-worth based on an evaluation of her body weight and shape. This is a hallmark feature of both anorexia and bulimia nervosa, as specified in the 4th ed. of the Diagnostic and Statistical Manual of Mental Disorders. The purpose of this study was to further our understanding of weight-related self-evaluation in eating-disordered women. METHOD: Eating-disordered patients, restrained eaters, and unrestrained eaters completed an experimenter-designed questionnaire that examines different dimensions of weight-related self-evaluation (i.e., the Multidimensional Weight-Related Self-Evaluation Inventory). RESULTS: Results revealed that weight-related self-evaluation is a feature shared, to some extent, by both eating-disordered patients and restrained eaters. However, eating-disordered patients extend weight-related self-evaluation to include more domains of self-esteem than did restrained eaters. DISCUSSION: These findings support a multidimensional approach to weight-related self-evaluation and further our understanding of the process of weight-related self-evaluation in eating-disordered patients.

Adult↗

Eating motives and the controversy over dieting: eating less than needed versus less than wanted.

Anti-dieting sentiment has grown in recent years. Critics of restrained eating suggest that it evokes counter-regulatory responses that render it ineffective or even iatrogenic. However, restrained eaters are not in negative energy balance and overweight individuals show reduced eating problems when losing weight by dieting. A distinction is often drawn between physiological and psychological hunger, and neuroscience research has shown that there is a neurophysiological reality underlying this distinction. The brain has a homeostatic system (activated by energy deficits) and a hedonic system (activated by the presence of palatable food). The omnipresence of highly palatable food in the environment may chronically activate the hedonic appetite system, producing a need to actively restrain eating not just to lose weight but to avoid gaining it. Just as restricting energy intake below homeostatic needs produces physiological deprivation, restricting intake of palatable foods may produce "perceived deprivation" despite a state of energy balance. In summary, the motivation to eat more than one needs appears to be every bit as real, and perhaps every bit as powerful, as the motivation to eat when energy deprived.

Animals↗

Improved eating behavior in eating-disordered inpatients after treatment: documentation in a naturalistic setting.

OBJECTIVE: Abnormalities of eating behavior are definitional components of eating disorders (ED), but are seldom observed directly. This study assessed abnormalities of eating behavior in ED patients before treatment and documented changes after multidisciplinary treatment. METHOD: Thirty-three ED patients (13 ANR, 10 ANB, 10 BN) and 10 controls selected a lunch meal in a cafeteria before and after treatment with energy intake (kilocalories) and macronutrients covertly observed. Visual analog scales (VAS) measured hunger and satiety. RESULTS: Before treatment, all ED patient groups experienced low hunger and high fullness, compared to controls. After treatment, hunger increased and satiety decreased. ANR patients, after treatment, increased energy intake from 366 to 916.5 kcal (p < .001), while BN patients increased from 409.9 to 663 kcal (p = .03). ANB nonsignificantly increased. ANR chose significantly more fats (22.7% to 36.2%, p = .05). DISCUSSION: Treatment partially normalizes pre-meal hunger and satiety in ED patients and significantly improves eating behavior (total energy intake and fat content) in ANR and BN patients. Reasons for nonsignificant changes in ANB are not obvious. We recommend documentation of eating behavior by simple, inexpensive, observational methods in a naturalistic setting before and after treatment of ED patients.

Adolescent↗

Developmental onset of eating-related color-naming interference: the role of restraint and eating psychopathology.

OBJECTIVE: This study investigated the developmental onset of the Stroop interference effect for food and body shape words in 12- and 14-year-old females to determine whether dietary restraint and eating psychopathology influenced Stroop performance times. METHOD: A Stroop task containing neutral, food, and body shape-related words was administered to 152 schoolgirls. Participants completed the restraint scale of the Dutch Eating Behavior Questionnaire and the Drive for Thinness (DFT) subscale of the Eating Disorders Inventory. RESULTS: Significant color-naming impairments were observed for food-related words in 12- and 14-year-olds, in 14-year-old restrained eaters, and in 12-year-old unrestrained eaters. There were no significant differences between restrained and unrestrained eaters in either age group. Participants scoring high on the DFT subscale showed significant impairments for food-related words, but did not differ significantly from those scoring low on the DFT. There were no significant impairments in color-naming body shape-related words in any subgroups. DISCUSSION: This study did not confirm a different developmental onset for the food and body shape Stroop interference effect. Consideration of dietary restraint did add clarity to previously observed food-related interference effects in both age groups. The results for high- and low-DFT participants do not support the use of the eating-related Stroop tests as an early objective indicator of eating psychopathology.

Adolescent↗

Eating related and general psychopathology in obese females with binge eating disorder.

One hundred obese women with a mean age of 39.2 years, and a mean body mass index (BMI) of 35.9 kg/m2 were evaluated before entering a treatment study for weight reduction. According to the results of a structured interview, subjects were divided into four groups: (1) no overeating episodes, (2) episodic overeating episodes without the feeling of loss of control, (3) overeating plus the sense of loss of control (binge eating), and (4) full diagnostic criteria for binge eating disorder (BED). One-way analyses of variance (ANOVAs) revealed significant positive associations between binge eating and eating/weight-related characteristics such as a history of frequent weight fluctuations, the amount of time spent dieting, drive for thinness, and a tendency for disinhibition of eating. Furthermore, subjects exhibited more feelings of ineffectiveness, stronger perfectionistic attitudes, more impulsivity, less self-esteem, and less interoceptive awareness the more problems with binge eating they reported. The results support the idea that binge eaters might be a distinct subgroup among the obese population, and corroborate the utility of a diagnosis of BED in identifying the most disturbed obese subjects with regard to the variables tested.

Adult↗

Investigating the structure of the eating inventory (three-factor eating questionnaire): a confirmatory approach.

OBJECTIVE: To investigate the internal structure of the Eating Inventory using confirmatory factor analytic (CFA) methods. METHOD: Female participants in a population-based twin study (N = 1,510) completed a reduced version of the Eating Inventory as part of a larger study of eating behaviors. Two CFA estimation methods were implemented using LISREL and Mplus to evaluate three different factor structures reported in the literature. RESULTS: Overall results for Stunkard and Messick's (1985) three-factor model indicated a poor fit to these data. The structure reported by Ganley resulted in an improper solution with factor correlations over 1 and several loadings estimated near 0 or with negative signs. The model proposed by Hyland et al. also fit poorly for all three models, the pattern of loadings on the Restraint factor proved most difficult to interpret. DISCUSSION: This study represents the first application of these confirmatory methods to the three subscales of the Eating Inventory. The instrument, as administered in this study, did not conform well to the structures proposed in previous studies. Because the Eating Inventory is recommended as a treatment planning tool, poor replication of the constructs purported to be assessed by this instrument underscores the importance of further internal validation research.

Adult↗

Emotional overeating and its associations with eating disorder psychopathology among overweight patients with binge eating disorder.

OBJECTIVE: The current study examined emotional overeating in overweight patients with binge eating disorder (BED). A new measure--the Emotional Overeating Questionnaire (EOQ)--was developed to measure the frequency of overeating in response to emotions. The internal consistency, test-retest reliability, and factor structure of this measure were examined, and its associations with eating disorder psychopathology, depression, and gender were explored. METHOD: Two hundred twenty consecutive overweight (body mass index [BMI] > or = 25) treatment-seeking BED patients (48 men and 172 women) were administered the EOQ, which assesses overeating frequency in response to six emotions (anxiety, sadness, loneliness, tiredness, anger, and happiness). A subset of patients (n = 83) completed the measure again approximately 1 week later. BMI was measured, and participants completed measures of eating disorder psychopathology. RESULTS: The EOQ was internally consistent (alpha =.85), its items were significantly and moderately correlated (range .32 to .70) with each other, and principal components analysis revealed one factor accounting for 58% of the variance. The EOQ items and total score were characterized by good test-retest reliability (intraclass correlation coefficients [ICCs] ranged from .62 to .73). Significant correlations were found between the emotional overeating items and total score, and binge frequency, eating disorder features, and depressive symptomatology. Emotional overeating was unrelated to BMI, and men and women reported similar rates of emotional overeating. CONCLUSION: Emotional overeating was significantly associated with binge frequency, eating disorder features, and depression, but was not related to BMI or gender.

Adult↗

Eating behavior in eating disorders: response to preloads.

Eating behavior in eating-disordered subjects was investigated by recording food intake and subjective ratings following three preloads differing in calories, weight and connotation. Subjects were patients with a DSM-IIIR diagnosis of anorexia nervosa or bulimia nervosa and nonpatient volunteers (normal-weight or overweight dieters, and normal-weight nondieters). After all preloads, anorectics ate significantly less than all other subjects except normal-weight dieters, and anorectics rated hunger and desire to eat consistently lower and fullness greater than all other subjects. When analysis of intake was adjusted for body weight, anorectics and normal-weight dieters still consumed significantly less than controls. Anorectics selected foods that were lower in fat and carbohydrate and ate a larger proportion of calories as protein than the other subjects. All groups decreased subsequent intake after the high-calorie preload except bulimics. This study demonstrates that the regulatory capacity of eating-disordered individuals can be investigated and that aberrant eating behavior was observed.

Adult↗

Eating style and symptoms of eating disorders: further explorations.

Based on earlier efforts to document relationships between eating styles involving hunger, deprivation, and restraint and symptoms of eating disorders, three scales--Eating Style, Feeling Deprived, and Dieting Style--were created and administered to 259 University females, 118 males, and 50 nonstudent females. Of interest were psychometric properties of the scales, their relationships to each other and with symptoms, beliefs about weight control, and body weight. One year later, findings based on Eating Style were replicated and extended in smaller groups of the original University subjects. Appreciable relationships occurred almost uniformly between Eating Style (addressing hunger, deprivation, and restraint) and proposed correlates. Feeling Deprived (a measure of avowed deprivation) correlated consistently with beliefs about weight control and weight variables, but not symptoms. Measurement of Dieting Style was hampered by small ns.

Adolescent↗

Eating disorders in Asian populations: a critique of current approaches to the study of culture, ethnicity, and eating disorders.

There is increasing evidence that eating disorders are present among ethnically diverse populations, and researchers have suggested that investigations in this area may inform the field's understanding of how sociocultural factors are related to the development of eating disorders. Although it is generally accepted that sociocultural factors are key in eating disorder etiology, knowledge on how best to study these influences in diverse groups is still limited. In this article, the authors review how the research literature has explored relationships among culture, ethnicity, and eating disorders in Asian populations and critically examine strategies that have been used to investigate these issues across 1 ethnic/racial group. The methodological challenges encountered in these approaches are identified and considered in the provision of recommendations for future endeavors to improve the field's understanding of how culture is related to eating disorders.

Adolescent↗

Peripheral and central signals in the control of eating in normal, obese and binge-eating human subjects.

The worldwide increase in the incidence of obesity is a consequence of a positive energy balance, with energy intake exceeding expenditure. The signalling systems that underlie appetite control are complex, and the present review highlights our current understanding of key components of these systems. The pattern of eating in obesity ranges from over-eating associated with binge-eating disorder to the absence of binge-eating. The present review also examines evidence of defects in signalling that differentiate these sub-types. The signalling network underlying hunger, satiety and metabolic status includes the hormonal signals leptin and insulin from energy stores, and cholecystokinin, glucagon-like peptide-1, ghrelin and peptide YY3-36 from the gastrointestinal tract, as well as neuronal influences via the vagus nerve from the digestive tract. This information is routed to specific nuclei of the hypothalamus and brain stem, such as the arcuate nucleus and the solitary tract nucleus respectively, which in turn activate distinct neuronal networks. Of the numerous neuropeptides in the brain, neuropeptide Y, agouti gene-related peptide and orexin stimulate appetite, while melanocortins and alpha-melanocortin-stimulating hormone are involved in satiety. Of the many gastrointestinal peptides, ghrelin is the only appetite-stimulating hormone, whereas cholecystokinin, glucagon-like peptide-1 and peptide YY3-36 promote satiety. Adipose tissue provides signals about energy storage levels to the brain through leptin, adiponectin and resistin. Binge-eating has been related to a dysfunction in the ghrelin signalling system. Moreover, changes in gastric capacity are observed, and as gastric capacity is increased, so satiety signals arising from gastric and post-gastric cues are reduced. Understanding the host of neuropeptides and peptide hormones through which hunger and satiety operate should lead to novel therapeutic approaches for obesity; potential therapeutic strategies are highlighted.

Adipocytes↗

Eating disorders and eating problems among adolescents with type 1 diabetes: exploring relationships with temperament and character.

OBJECTIVE: To determine temperament and character among adolescents with type 1 diabetes with and without disordered eating. METHOD: A clinical sample of 199 adolescents from multiple centers with a mean age of 14.1 (SD, 2.5) years were screened and diagnosed for eating disorders. Assessed were temperament and character as conceptualized by Cloninger, glycemic control, and depression. RESULTS: Adolescent patients with clinical eating disorders or subthreshold eating problems had significantly higher mean scores in harm avoidance and lower mean scores in self-directedness. Harm avoidance remained significant even after controlling for depressive pathology. DISCUSSION: This study is the first to show evidence that among youths (in particular, girls) with type 1 diabetes, there is an association between low self-directedness, high harm avoidance, and the presence of eating, weight, and shape pathology. For these particular youths, important implications for clinical practice are outlined.

Adolescent↗

Early childhood eating behaviors and adolescent eating disorders.

Maladaptive eating patterns were traced longitudinally in a large random sample of children. Pickiness and concern with weight were more common in girls than in boys, and the prevalence of pickiness declined with age. No age or sex differences in family contention around meals nor in bingeing were shown. All problem behaviors showed significant stability over the 10-year span studied, beginning at ages 1 to 10. Certain eating and digestive problems in early childhood were predictive of symptoms of bulimia nervosa and anorexia nervosa in adolescence. Findings regarding prospective risks implicate pica and problem meals in early childhood for later bulimia nervosa; suggesting problems in self-control of eating behavior as well as eating-related family struggles. Risks in early childhood for subsequent symptoms of anorexia nervosa include picky eating and digestive problems.

Adolescent↗

Eating habits and eating disorders during pregnancy.

A general population sample of 100 primigravid women was studied prospectively to describe the changes in eating that occur in pregnancy with particular reference to cravings and aversions and the behavior and attitudes characteristic of clinical eating disorders. Assessment was by standardized interview. Dietary cravings and aversions were found to be common and largely confined to early pregnancy. Eating disorder features decreased in severity early in pregnancy but increased later on. Dietary cravings rarely resulted in episodes of overeating like those seen in patients with eating disorders. In this study of a general population sample, no evidence was found of a relationship between pregnancy outcome and the severity of eating disorder features prior to pregnancy.

Adolescent↗

Cortisol, hunger, and desire to binge eat following a cold stress test in obese women with binge eating disorder.

OBJECTIVE: Increased basal cortisol levels have been found in bulimia nervosa. After stress, increased cortisol levels have been associated with increased food intake in healthy women. Therefore, we assessed cortisol, hunger, and desire to binge eat after a cold pressor test (CPT) among women with binge eating disorder (BED). METHODS: Twenty-two obese (body mass index [BMI] = 36.7 +/- 6.5 SD) females (11 non-BED, 11 BED) completed the Zung depression scale and underwent the CPT, hand submerged in ice water for 2 minutes. Over 60 minutes, periodic ratings of hunger and desire to binge eat were obtained, just before blood draws for cortisol, as well as insulin. On a separate day, participants had a 1-mg oral dexamethasone suppression test (DST). RESULTS: The BED group had higher depression scores than the non-BED (p = .04), but depression was not a significant covariate for the cortisol response or to DST. After controlling for contraceptive use (n = 3), the BED group had higher basal cortisol than the non-BED group (p = .03), but cortisol did not differ after DST (p = .40). The BED group had nearly significant greater cortisol AUC after the CPT (p = .057) after controlling for insulin AUC and contraceptive use (p = .057). The BED group also had greater AUC for hunger (p = .03) and desire to binge eat (p = .02) after the CPT. CONCLUSION: These findings support our hypothesis of a hyperactive HPA-axis in BED, which may contribute to greater hunger and binge eating.

Adult↗

[Nocturnal eating disorder--sleep or eating disorder?].

Nocturnal eating disorder (NED) is a rare syndrome that includes disorders of both eating and sleeping. It is characterized by awakening in the middle of the night, getting out of bed, and consuming large quantities of food quickly and uncontrollably, then returning to sleep. This may occur several times during the night. Some patients are fully conscious during their nocturnal eating, while some indicate total amnesia. The etiology of NED is still unclear, as research findings are contradictory. Those suffering from NED exhibit various levels of anxiety and depression, and many lead stressful life-styles. Familial conflict, loneliness and personal crises are commonly found. Recently, a connection has been discovered between NED and unclear self-definition, faulty interpersonal communication, and low frustration threshold. Several authors link it to sleepwalking, leg movements during sleep, and sleep apnea. Treatment is still unclear and there have been trials of pharmacotherapy, psychotherapy, or a combination of both. However, pharmacological treatment has generally been found to be the most effective, although each case must be considered individually. In 1998, 7 women referred to our Eating Disorders Clinic, 5% of all referrals, were subsequently diagnosed as suffering from NED. Of these, 3 suffered from concurrent binge-eating disorder and 4 also from bulimia nervosa. 2 case studies representative of NED are presented.

Adult↗

[Measuring the development of eating disorders in a group of patients with the Eating Disorders Inventory (EDI)].

The Eating Disorders Inventory (EDI I) has been applied to four groups of patients with Eating Disorders (ED): Anorexic Bulimic Subtype (AB N = 22), Anorexic Restrictive Subtype (AR N = 36); Bulimic (B N = 51) and Other Eating Disorders (OED N = 15), according to the DSM III-R criteria. We have also applied the Eating Attitude Test (EAT-40), the Beck Depression Inventory (13 items), the Hamilton Anxiety Rating Scale and the Hamilton Depression Rating Scale. During their hospital care, the patients have been treated by cognitive-behavioural therapy. The order or decreasing total scores in EDI at the admission is the B subtype, then the AR subtype, then the OED group. In total score, the B and AB improved more than the order groups, between their admission and a second assessment three months later. Body dissatisfaction, Drive for thinness and Interpersonnal distrust are the only subscales for which no group showed a statistical improvement after three months. The B group decreased more in the subscale, than the other groups, particularly in Interoceptive awareness, Ineffectiveness and bulimia.

Adult↗