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Medial prefrontal cortex activity associated with symptom provocation in eating disorders.

OBJECTIVE: The authors sought to identify neural correlates of eating disorders in order to contribute to the debate on the genesis and classification of eating disorders and provide endophenotypes for genetic research. METHOD: Twenty-six female patients with eating disorders (10 with bulimia nervosa, 16 with anorexia nervosa) and 19 healthy female comparison subjects matched for age and education were presented with food and aversive emotional images while brain activity was recorded with functional magnetic resonance imaging. RESULTS: Women with eating disorders identified the food stimuli as threatening and disgusting. In response to these stimuli, the women with eating disorders had greater activation in the left medial orbitofrontal and anterior cingulate cortices and less activation in the lateral prefrontal cortex, inferior parietal lobule, and cerebellum, relative to the comparison group. In addition, women with bulimia nervosa had less activation in the lateral and apical prefrontal cortex, relative to the comparison group. Between-group differences in response to nonspecific emotional stimuli were found in the occipital cortex, parietal cortex, and cerebellum. CONCLUSIONS: A medial prefrontal response to symptom-provoking stimuli was identified as a common feature of anorexia and bulimia nervosa. This finding supports a conceptualization of eating disorders as being transdiagnostic at the neural level. The abnormal prefrontal reaction is associated with symptom-related material, whereas the occipital and cerebellar differences are nonspecific. An abnormal propensity to activate medial prefrontal circuits in response to inappropriate stimuli is common to eating, obsessive-compulsive, and addictive disorders and may account for the compulsive features of behavior in these conditions.

Adult↗

Prevalence of the night eating syndrome in a psychiatric population.

OBJECTIVE: This study assessed the prevalence of night eating syndrome and its comorbid psychopathology in a psychiatric population. METHOD: The Night Eating Questionnaire was administered to 399 patients in two psychiatric outpatient clinics. Those scoring above 20 on the questionnaire (N=205) were assessed for night eating syndrome with a semistructured telephone interview. Chart reviews of all participants were performed to determine their psychiatric diagnoses and medications. RESULTS: Forty-nine participants (12.3%) met criteria for night eating syndrome. Greater rates of substance use disorders were found among patients diagnosed with night eating syndrome than among those without the syndrome. Obese patients were more likely than nonobese patients to manifest night eating syndrome. CONCLUSIONS: Night eating syndrome is prevalent among psychiatric clinic outpatients and is likely to co-occur with substance use disorders and obesity.

Adult↗

Premenstrual dysphoric disorder and eating disorders.

UNLABELLED: Premenstrual Dysphoric Disorder (PMDD) can be differentiated from Premenstrual Syndrome (PMS) by the use of the research criteria provided by the Diagnostic and Statistical Manual (DSM) IV. Indeed, PMS corresponds to mild clinical symptoms, such as breast tenderness, bloating, headache and concomitant minor mood changes, while premenstrual magnification occurs when physical and psychological symptoms of a concurrent axis I disorder get worse during the late luteal phase. Changes in appetite and eating behavior have been documented in women suffering from PMS, with an increased food intake occurring during the luteal phase. Moreover, in women with PMS, a major effect of the phase of the menstrual cycle on appetite has been documented and a high correlation with self-ratings of mood, particularly depression, has been described only in such disturbance. The aim of the present study was to analyse the clinical similarities between PMDD and Eating Disorders (in particular Bulimia Nervosa and Binge Eating Disorder). Thus, we compared the DSM III-R comorbidity, the personality dimensions and the eating attitudes in these patients, attempting to identify any relationship between groups. Twelve PMDD women (mean age 28 years), diagnosed using DSM IV criteria and premenstrual assessor form, were compared with 10 eating disorder (ED) women (6 Bulimia Nervosa, 4 Binge Eating Disorder) (mean age 25 years) and with 10 control women matched for age. The following instruments were used: (i) clinical interview with DSM III-R criteria (SCID); (ii) a psychometric study with TPQ for the evaluation of three personality dimensions (novelty seeking, harm avoidance and reward dependence); (iii) EAT/26 for the evaluation of eating attitudes. Results show that a high comorbidity for mood and anxiety disorders in PMDD and ED is well documented. Our PMDD patients share a 16.6% of comorbidity with ED, whereas such an association is present only in 2.3% of the general population. In addition, as a common clue, the personality dimension, harm avoidance, linked to a serotonin mediation is significantly more frequent in PMDD and ED than in normal controls. IN CONCLUSION: from the present study it seems clear that a certain degree of similarity exists between the PMDD and ED. However, whether or not these two disorders really share common ground from a physiopathological point of view still has to be clarified by more extensive studies.

Adolescent↗

Eating attitudes as related to demographic and personality characteristics: a high school survey.

A survey of 577 high school students was conducted to assess attitudes toward eating and their relationship to demographic and personality characteristics. Students completed a demographic questionnaire, and Eating Attitude Test (EAT-26) and the Basic Personality Inventory (A-BPI). When a cut-off score of 20 on EAT-26 was applied, overall prevalence of disordered eating attitude was found to be 7.5%. Groups scoring in pathological versus normal ranges showed no significant difference in mean age, socioeconomic status or race. The former group reported significantly shorter height and lower body weight. Of the subjects, 6.06% reported weight below the 10th percentile. This subgroup did not vary from those above the 10th percentile on sociodemographic and psychopathological variables, nor in prevalence of abnormal eating attitudes. Analysis of the A-BPI data showed subjects with abnormal eating attitudes had increased psychopathology in several areas, with greater neurotic tendencies, lower self-esteem and higher levels of deviant thinking and behaviour.

Adolescent↗

Views on classification and diagnosis of eating disorders.

OBJECTIVE: To highlight developments in the taxonomy of eating disorders since Russell's original description of bulimia nervosa (BN) in 1979 and through 3 versions of the Diagnostic and Statistical Manual. METHOD: Criteria for anorexia nervosa (AN), BN and binge eating disorder (BED) are systematically described. RESULTS: While criteria for AN remain largely unchanged between DSM-III-R and DSM-IV, the subclassification of binge/purge and restricter subgroups endorses previous research findings. For BN, the definition of "binge" has occupied considerable attention both in quantitative and qualitative terms. The arbitrary choice of 2 episodes per week as a minimum frequency is also discussed in light of recent data from the Ontario Health Supplement. A third eating disorder, BED, is now included in the appendix of DSM-IV under Eating Disorders--Not Otherwise Specified category. The potential overlap between this disorder and nonpurging BN is discussed. Finally, the relationship between eating disorders and other psychiatric disorders including depression, schizophrenia, obsessional, and conversion disorders is considered as well as the continuum from preoccupation with weight to eating disorder. CONCLUSION: While significant advances have been made in understanding and classifying eating disorders during the past 15 years, further empirical work is necessary to clarify areas of uncertainty.

Anorexia Nervosa↗

Cutaneous manifestations of eating disorders.

BACKGROUND AND OBJECTIVE: No complete review of the cutaneous manifestations of eating disorders exists. We therefore, set out to review and systematically describe the clinical and histopathologic features of dermatologic conditions associated with anorexia nervosa, bulimia nervosa, and obesity. Differential diagnosis, pathophysiology, laboratory studies, and treatment are also reviewed. METHODS: Index Medicus review (1966 to present) using Ovid-MEDLINE. Search terms included eating disorders, anorexia nervosa, bulimia nervosa, eating disorders not otherwise specified (ED-NOS), and obesity, as well as the terms dermatology skin and cutaneous manifestations, with cross-referencing sources. These were combined with our own clinical experience. All relevant publications, including case reports, case series, cohort studies, and histopathologic studies giving at least Level II-3 evidence (evidence from comparisons between times or places with or without the intervention, including dramatic results in uncontrolled experiments), were selected. CONCLUSION: Forty dermatological signs have been reported in eating disorder patients. Eating disorders have many cutaneous manifestations and cutaneous signs may lead to the diagnosis of an occult eating disorder. The resolution of skin eruptions in eating disorder patients often depends on treatment of the underlying disorder.

Acrodermatitis↗

Eating attitudes and neurotic symptoms in university students.

A postal survey of male and female university students is reported, using the Eating Attitude Test (EAT) and the Crown Crisp Experiential Index (CCEI). Eleven per cent of the 156 female respondents but none of 120 males scored above 30 on the EAT, thereby declaring eating attitudes comparable to anorexic subjects. Of those interviewed, none fulfilled diagnostic criteria for anorexia nervosa, but half showed eating disorder of clinical severity. There was a clear association between high EAT scores and higher scores on all the subscales of the CCEI except the phobic scale. The results are discussed in relation to ideas about the possible origins of clinical eating disorders.

Adolescent↗

Instability of eating disorder diagnoses: prospective study.

BACKGROUND: The stability of eating disorder diagnoses has received little research attention. AIMS: To examine the course of the full range of clinical eating disorders. METHOD: A sample of 192 women with a current DSM-IV eating disorder (55 with anorexia nervosa,108 with bulimia nervosa and 29 with eating disorder not otherwise specified) were assessed three times over 30 months using a standardised interview. RESULTS: Although the overarching category of "eating disorder" was relatively stable, the stability of the three specific eating disorder diagnoses was low, with just a third of participants retaining their original diagnosis. This was due only in part to remission since the remission rate was low across all three diagnoses. CONCLUSIONS: There is considerable diagnostic flux within the eating disorders but a low overall remission rate. This suggests that underpinning their psychopathology may be common biological and psychological causal and maintaining processes.

Adolescent↗

Are oral, obsessive, and hysterical personality traits related to disturbed eating patterns? A general population study of 6,313 men and women.

In this study, we explored 3 psychodynamically defined personality traits as predictors of eating disturbances among men and women in the general population. The Basic Character Inventory (Torgersen, 1980) was used to measure oral, obsessive, and hysteria traits along with the Eating Disturbance Scale (Rosenvinge et al., 2001). Oral personality factors were the primary predictors of eating disturbances in both genders-both men and women with eating disturbances tended to score highly on measures of emotional instability, self-doubt, compliance, and sensitivity. In women, the presence of oral personality factors in addition to the absence of the obsessive factor Parsimony accounted for 16% of the variance in eating disturbances. In men, oral personality factors in addition to the presence of the hysterical factor Imagination accounted for 13% of the variance in eating disturbances. This last finding suggests that, in addition to oral characteristics, men with eating disturbances may exhibit dissociative traits and imaginative absorption.

Adult↗

Emerging drugs for eating disorder treatment.

Anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED) comprise the currently recognised eating disorders. Although distinct diagnostic entities, they share certain forms of comorbid psychopathology, particularly anxiety and mood disorders. BN and BED have been studied most intensively as targets for pharmacotherapy. The list of drugs tested in eating disorders is substantial; however, the number of therapeutic classes of medications tested in these conditions is relatively modest. Antidepressant medications, including tricyclic antidepressants, selective serotonin re-uptake inhibitors, as well as some of the novel antidepressants, have shown evidence of some therapeutic value in both BN and BED. Their efficacy in AN, however, has been disappointing. The pharmacological options for AN are very limited. The number of controlled trials that have been conducted is small, and the research that has been successfully completed has generally failed to demonstrate medication efficacy. Patients with BN typically show reduced binge eating and purging frequency in medication trials, but rarely attain abstinence. In BED, patients often measure the value of their medication therapy by its ability to stimulate weight loss, which is another area on which future pharmacotherapy may improve. Novel pharmacological interventions are needed for each of these conditions. Peptide hormones are increasingly being evaluated for eating disorder treatment, including ghrelin agonists, neuropeptide Y1 and -5 antagonists, orexin receptor antagonists, corticotropin-releasing factor receptor 2 antagonists, histamine 3 antagonists, melanocortin 4 receptor antagonists, beta3-adrenoceptor agonists, 5-hydroxytryptamine-2A antagonists and growth hormone agonists. Although these compounds are in early phases of clinical testing for eating disorder treatments, data from these studies will be instructive in the quest for effective pharmacotherapy for these conditions. An overview of the current pharmacotherapy options for eating disorders is presented with a discussion of the emerging potential treatments.

Anorexia Nervosa↗

Hormonal changes related to eating behavior in oligomenorrheic women.

The aim of this study was to determine those hormonal alterations in the gonadotropin-ovarian axis that are related to eating behavior in oligomenorrheic patients. We studied 74 oligomenorrheic women aged 26.2 +/- 0.8 years, divided into group IA (N = 13) with eating disorders, group IB (N = 61) without eating disorders and 18 normally cycling controls aged 29.2 +/- 1.6 years (group II). No subject had ovarian failure, pituitary disease, thyroid dysfunction or was taking any drug. Blood samples were taken on days 3-6 after the last menses. Luteinizing hormone (LH) was measured in two plasma pools, each made up of three samples taken at 30-min intervals, starting at 15.00 h (LH-15h) and 09.00 h (LH-9h), which allowed the mean LH (mLH) and variability in LH (V-LH: percentage increase from the lower to the higher of the two LH values) to be calculated. Follicle-stimulating hormone (FSH), sex steroids, and gonadotropin-releasing hormone-stimulated LH (sLH) and -FSH (sFSH) were also evaluated. Eating behavior was evaluated with the EAT questionnaire; the EAT 26 score, the dieting score (DS) and bulimia score (BS) were calculated. Dietary intake was evaluated in 35 group IB patients based on food diaries analyzed with the REGAL program, to evaluate daily calorie intake (Cal) and calories provided by carbohydrates (Carb), lipids (Lip) and proteins (Prot). Comparisons between groups were done by analysis of variance (followed by the Fisher PLSD test) and the Kruskal-Wallis test. Groups IA, IB and II did not differ regarding age, body mass index, LH-9h, LH-15h, mLH, FSH, sLH, sFSH, estradiol or dehydroepiandrosterone sulfate; group IA had a higher V-LH than group II (p < 0.02) and a higher testosterone level than groups IB and II (p < 0.05). Positive correlations were found between V-LH and DS (p < 0.01) and BS (p < 0.05), and between testosterone and BS (p < 0.02) and DS (p < 0.05). The V-LH was negatively correlated with Cal and Carb, and testosterone was positively correlated with Cal and Lip. In patients referred for oligomenorrhea, it is concluded that testosterone levels and variability of LH levels are related to eating behavior.

Adult↗

[Genetics in eating disorders: extending the boundaries of research].

OBJECTIVE: To review the recent literature relevant to genetic research in eating disorders and to discuss unique issues which are crucial for the development of a genetic research project in eating disorders in Brazil. METHOD: A computer literature review was conducted in the Medline database between 1984 and may 2005 with the search terms "eating disorders", "anorexia nervosa", "bulimia nervosa", "binge eating disorder", "family", "twin" and "molecular genetic" studies. RESULTS: Current research findings suggest a substantial influence of genetic factors on the liability to anorexia nervosa and bulimia nervosa. Genetic research with admixed populations should take into consideration sample size, density of genotyping and population stratification. Through admixture mapping it is possible to study the genetic structure of admixed human populations to localize genes that underlie ethnic variation in diseases or traits of interest. CONCLUSIONS: The development of a major collaborative genetics initiative of eating disorders in Brazil and South America would represent a realistic possibility of studying the genetics of eating disorders in the context of inter ethnic groups, and also integrate a new perspective on the biological etiology of eating disorders.

Anorexia Nervosa↗

Eating disorders, serotonin transporter polymorphisms and potential treatment response.

Anorexia nervosa, bulimia nervosa, and binge eating disorder are eating disorders with common clinical and psychological features, potentially shared mechanisms, significant morbidity and, at least for anorexia nervosa, a high mortality rate. Among the numerous risk factors involved, the importance of a genetic vulnerability has been demonstrated, and the heritability, in the broad sense, has being estimated to be between 50 and 70%. Studies have thus focused on different candidate genes. Serotonin transmission and regulation has been extensively studied with regard to its role in core mechanisms such as feeding and fasting, but also in different clinical characteristics of eating disorders. The serotonin transporter (5-HTT), encoded by the SLC6A4 gene, may also have an important role in eating disorders, as its availability is decreased in patients with bulimia nervosa and binge eating disorder. The promoter region contains a functional insertion/deletion polymorphism with two common alleles that have been designated the short (*S) and long (*L) alleles. The frequency of the SLC6A4*S allele has been assessed in four independent samples of patients with anorexia nervosa, but gave discrepant results. A meta-analysis was performed, which showed that the *S allele could represent a moderate but significant risk factor that increases the risk of anorexia nervosa (odds ratio [OR] = 1.38, 95% confidence interval [CI] 1.16-1.72). Eating disorders are treated using different types of psychotherapy and pharmacotherapy with antidepressants; serotonin reuptake inhibitors being the most frequently prescribed. High doses of selective serotonin reuptake inhibitors (SSRIs) are usually prescribed in eating disorders. The prevalence of non-responders (roughly one out of two), and the presence of a functional genetic polymorphism in the promotor region of SLC6A4, emphasizes the potential utility of psychopharmacogenetics in prescribing SSRIs in the treatment of patients with weight-restored anorexia nervosa. Information about genetic variations of cytochrome P450 could also facilitate pharmacotherapy by preventing the administration of high doses in poor metabolizers and identify rapid metabolizes who may require higher doses for efficacy. SLC6A4 genotyping would allow physicians to individualize selective serotonin reuptake therapy for their patients.

Carrier Proteins↗

Eating disorders in female adolescents with insulin dependent diabetes mellitus.

Recent case reports have suggested an association between anorexia nervosa and/or bulimia with insulin-dependent diabetes mellitus (IDDM). Fifty-eight females aged fifteen to twenty-two with IDDM for more than one year were assessed for the presence of eating disorders. Patients were screened for eating and weight pathology using the Eating Disorder Inventory (EDI) and Eating Attitudes Test-26 (EAT-26). Glycosylated hemoglobin (HbA1) was measured to assess metabolic control. Subjects who scored above the cut-off points associated with eating and weight pathology were interviewed. Clinically significant eating and weight pathology was found in 20.7 percent of the population. Of these subjects, anorexia nervosa was found in 6.9 percent and the syndrome of bulimia, based on DSM-III criteria, was found in 6.9 percent. In patients with bulimia, there was a strong inverse correlation between bulimic symptoms and metabolic control. These findings suggest that anorexia nervosa may be more common in female adolescents with IDDM than in nondiabetic populations and that bulimic symptoms may be a risk factor for poor metabolic control.

Adolescent↗

Prevalence of eating disorder symptoms in preadolescent and adolescent girls with IDDM.

OBJECTIVE: To assess attitudinal and behavioral symptoms of eating disorders in preadolescent and adolescent girls with IDDM and a matched sample of nondiabetic subjects, and to explore the relationship between the perceived impact of IDDM and eating disorder symptoms. RESEARCH DESIGN AND METHODS: All eligible IDDM patients (girls, age 8-18 yr) from the case register of the Yale Children's Diabetes Clinic were recruited for this study. Of 49 eligible patients, 46 participated in the study. Control subjects were recruited among students in several local schools; 46 girls, individually age and race-matched with IDDM patients, and group-matched by father's socioeconomic status, were included in this study. All subjects participated in an investigator-based clinical interview (EDE) and completed a self-report measure of eating-related psychopathology (EDI). IDDM subjects completed the DQOL measure to determine the perceived impact of diabetes on patients' lives. RESULTS: IDDM patients reported significantly more regular consumption of meals and snacks than did nondiabetic subjects. No group differences were found on measures of symptoms of eating disorders: both groups reported minimal levels of symptoms. Among adolescent IDDM patients, eating disorder symptoms were related significantly to patients' dissatisfaction with the illness and its impact on their lives. CONCLUSIONS: It appears that when applying stringent diagnostic procedures and matching criteria, IDDM girls do not evidence an elevated prevalence of eating disorder symptoms. However, those IDDM patients who did report symptoms may be a high-risk group for the development of an eating disorder and should be followed prospectively.

Adolescent↗

Eating disorders and IDDM. A problematic association.

IDDM and eating disorders are common conditions in young women. Whether a specific association exists between these two disorders remains controversial. Some studies have suggested an increased incidence of eating disorders in young women with IDDM, whereas others have not detected such an increase. These differences may be attributable, at least in part, to methodological issues in study design, measurement tools, and relatively small sample sizes. Whether the prevalence of eating disorders in IDDM is increased will be resolved only by larger studies that use standardized diagnostic interviews. We suspect that certain aspects of IDDM and its management may trigger the expression of an eating disorder in susceptible individuals. Required dietary restraint and weight gain related to diabetes management are the factors most likely to be implicated. Eating disorders are relatively common in young women with IDDM and may contribute to impaired metabolic control with hypoglycemia and DKA, and to long-term microvascular complications of diabetes. Omission or reduction of required insulin, an extremely common means of weight control in these young women, is likely an important factor in this regard. Further research is required to determine more precisely the relationship between IDDM and eating disorders, and the effects of eating disorders on metabolic control and chronic complications of IDDM.

Bulimia↗

A comparison of eating behaviors in newly diagnosed NIDDM patients and case-matched control subjects.

OBJECTIVE: To determine whether disordered eating may be problematic in non-insulin-dependent diabetes mellitus (NIDDM). RESEARCH DESIGN AND METHODS: We contrasted the eating behaviors and attitudes in 50 newly diagnosed NIDDM patients with 50 age-, sex-, and weight-matched control subjects. RESULTS: Although 14% of diabetic subjects versus 4% of nondiabetic subjects reported episodes of binge eating (P < 0.10), there was no difference between diabetic and nondiabetic subjects in the prevalence with which they met criteria for binge eating disorder. Diabetic patients with a history of binge eating were significantly heavier, had younger age at diagnosis, and had more problems with eating in response to situational and emotional cues than did diabetic patients who did not binge. CONCLUSIONS: No support was found for greater prevalence of binge eating disorder in newly diagnosed NIDDM patients than in matched nondiabetic control subjects.

Adult↗

Subclinical eating disorders and glycemic control in adolescents with type I diabetes.

Several recent case reports have shown that anorexia nervosa and bulimia negatively affect glycemic control in diabetic patients. However, there have been no systematic studies to assess the prevalence of clinical or subclinical eating disorders among diabetic patients or to determine the impact of such disturbances on glycemic control. This study reports a survey of 202 adolescents, aged 12-18 yr, seen in the Diabetes Clinic, Children's Hospital of Pittsburgh, who were asked to complete the Binge Eating Scale (BES) and the EAT-26 questionnaire. Responses of diabetic patients to the EAT-26 questionnaire were compared with those of a nondiabetic control group and were related to measures of glycemic control. Diabetic subjects scored higher on the total EAT-26 than nondiabetic control subjects, ordinarily indicative of more eating pathology. However, diabetic subjects scored higher only on the dieting subscale of this questionnaire, probably reflecting adherence to the diabetes dietary regimen. Subjects with diabetes scored lower, or did not differ significantly, from nondiabetic control subjects on measures of oral control and bulimia. Among diabetic subjects, self-reported bulimic behaviors were related to poorer glycemic control. Patients with the highest scores on the BES had an average HbA1 of 13.1% compared with 11.8% for age- and sex-matched patients at the 50th percentile, and 10.8% for patients in the lowest 10th percentile. Further studies are needed to determine whether modification of these eating behaviors would improve glycemic control.

Adolescent↗