Anorexia nervosa and bulimia nervosa: I. Diagnosis and treatment

Disturbed eating behaviour and disturbed body experience are important features for the differential diagnosis of eating disorders from other disorders. Eating disorders occur mainly in young females. The one-year prevalence of anorexia nervosa is 0.4% and that of bulimia nervosa 1.5% among young females. To motivate patients for treatment it is important to discuss physical problems and the high risk of severe complications with them. It is difficult to motivate patients for treatment, because anorexia nervosa patients deny their illness and bulimia nervosa patients are ashamed and hide their disturbed eating behaviour. The treatment of anorexia nervosa consists of two partly overlapping phases: normalizing the eating pattern to improve weight restoration and psychotherapeutic treatment for underlying emotional problems. Family therapy is effective for patients younger than 18 years with a short duration of illness. Cognitive behaviour therapy is the most important form of treatment for bulimia nervosa.     

Gastrointestinal and nutritional aspects of eating disorders

Anorexia nervosa (AN) and bulimia nervosa (BN) are potentially fatal eating disorders which primarily affect adolescent females. Differentiating eating disorders from primary gastrointestinal (GI) disease may be difficult. GI disorders are common in eating disorder patients, symptomatic complaints being seen in over half. Moreover, many GI diseases sometimes resemble eating disorders. Inflammatory bowel disease, acid peptic diseases, and intestinal motility disorders such as achalasia may mimic eating disorders. However, it is usually possible to distinguish these by applying the diagnostic criteria for eating disorders and by obtaining common biochemical tests. The primary features of AN are profound weight loss due to self starvation and body image distortion; BN is characterized by binge eating and self purging of ingested food by vomiting or laxative abuse. GI complications in eating disorders are common. Recurrent emesis in BN is associated with dental abnormalities, parotid enlargement, and electrolyte disturbances including metabolic alkalosis. Hyperamylasemia of salivary origin is regularly seen, but may lead do an erroneous diagnosis of pancreatitis. Despite the weight loss often seen in eating disorders, serum albumin, cholesterol, and carotene are usually normal. However, serum levels of trace metals such as zinc and copper often are depressed, and hypophosphatemia can occur during refeeding. Patients with eating disorders frequently have gastric emptying abnormalities, causing bloating, postprandial fullness, and vomiting. This usually improves with refeeding, but sometimes treatment with pro-motility agents such as metoclopromide is necessary. Knowledge of the GI manifestations of eating disorders, and a high index of suspicion for one condition masquerading as the other, are required for the correct diagnosis and management of these patients.     

Gender issues and eating disorders

Sexual problems are not specific for eating disorders. The etiology is complex and no one single causal facter has been identified. However, clinical as well as epidemiological studies have shown that eating disorders occur more commonly in females than males. The evidence that eating disorders are more common in females has resulted in the postulation that socio-cultural factors may be important. An important aspect of the socio-cultural position of women which may contribute to eating disorders is the conflict in roles. Clinical experience and research have shown the important role of sexual problems and traumas in the development of anorexia nervosa and bulimia. When compared to anorexics, bulimics reported greater sexual interest and activity.     

Patterns and predictors of recovery in anorexia nervosa and bulimia nervosa

OBJECTIVE: The purpose of this study was to assess the course and outcome of anorexia nervosa and bulimia nervosa at 1 year in a large cohort of women with eating disorders. METHOD: A prospective, naturalistic, longitudinal design was used to map the course of 225 women with anorexia nervosa, bulimia nervosa, and mixed anorexia and bulimia nervosa. Structured interviews were conducted quarterly. Follow-up data are presented in terms of patterns of recovery, clinical features predictive of time to recovery, and the role of comorbid disorders as fixed predictors. RESULTS: The recovery rate of bulimics was significantly better than that of anorexic or mixed subjects, yet nearly half the anorexic and mixed subjects no longer met full DSM-III-R criteria for at least 8 consecutive weeks during the first year of follow-up. Percent ideal body weight and type of eating disorder were significantly associated with outcome. CONCLUSIONS: Our findings suggest that the diagnosis of anorexia nervosa has severe implications.     

Treatment of eating disorders in children and adolescents

Anorexia nervosa and bulimia nervosa are expressed differently in children and adolescents than in adults. Consequently, diagnostic procedures and multidisciplinary treatments need to be tailored to the unique developmental, medical, nutritional, and psychological needs of children and adolescents with eating disorders. This paper reviews current research outlining the differences between child, adolescent, and adult eating disorders. Research is then reviewed concerning the effectiveness of hospitalization, partial hospitalization, individual dynamic therapy, cognitive-behavioral therapy, interpersonal therapy, family therapy, and medication for treating anorexia nervosa, bulimia nervosa, and related eating disorders in children and adolescents. Specific recommendations are made for practitioners to tailor these treatments to their eating-disordered child and adolescent patients, following a stepped-care, decision-tree model of intervention that takes into account the effectiveness, cost, and intrusiveness of the interventions.     

Mapping of a congenital microcoria locus to 13q31-q32

The growth and timing of female puberty in a seasonally breeding marsupial, the tammar wallaby, was examined in wild and captive animals. Puberty, defined as the time of first estrus and ovulation, can occur at any time of the year. Sixty percent of young wild females went through puberty in late October-November, 3 mo before the normal adult mating season in late January-February, but puberty was delayed in captive animals kept with a low ratio of males to females. During initial cycles, 19% of these captive animals were infertile as judged by failure to conceive. In the wild, puberty occurred well before the animals were fully grown (body weight 2.0+/-0.3 kg [mean+/-SD], n=23; adult females, 4.7+/-0.6 kg; n=34). Only 3% of animals with a body weight below 1.5 kg had ovulated. Thus, attainment of a minimum body weight was a key prerequisite associated with puberty. Progesterone concentrations in the peripheral plasma of prepubertal females were not significantly different from those of adult females during the nonbreeding season (prepubertal, 142+/-121 pg/ml, n=34; adult, 194+/-105 pg/ml, n=32, p > 0.05). However, there was a significant increase in progesterone (322+/-242 pg/ml, n=32, p < 0.05) in the postpubertal females (ovulating but still < 3.5 kg body weight) even though the corpus luteum was quiescent after its formation. There was no increase in plasma progesterone before the first estrus. These data confirm that estrus does not require a change in the progesterone:estradiol ratio, and that a "silent" ovulation does not precede the first estrus in this species, so that the onset of puberty coincides with the first behavioral estrus and ovulation, when the animals have reached a body weight of 2 kg. Although adult female tammars are strict seasonal breeders, with 6 mo of seasonal quiescence from the winter to the summer solstice, young females can go through puberty at any time of the year. The unique feature of the female tammar wallaby is that it does not become a seasonally breeding mammal until after puberty, when it has acquired a corpus luteum.     

Scope and significance of eating disorders.

Anorexia nervosa and bulimia are major health concerns in many industrialized societies. Both disorders appear to be increasing in prevalence, and both (particularly anorexia nervosa) are associated with significant morbidity and mortality. Genetic studies have suggested that there may be a genetic risk for the development of anorexia nervosa. Various treatment strategies have been advocated for these conditions. Both pharmacotherapy and psychotherapy, particularly psychotherapy that incorporates cognitive-behavioral principles, appear to be useful. Recent biological studies on appetite and weight regulation are beginning to yield findings of clinical significance in the treatment of these disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The demand for eating disorder care. An epidemiological study using the general practice research database

BACKGROUND: An epidemiological study of anorexia nervosa and bulimia nervosa in primary care was performed using the General Practice Research Database (GPRD). METHOD: The GPRD was screened between 1988 and 1994 for newly diagnosed cases of anorexia nervosa and bulimia nervosa. The validity of the computer diagnosis was established by obtaining clinical details from a random sample of the general practitioners (GPs). RESULTS: Incidence rates for detection of cases by GPs in 1993 was 4.2 per 100,000 population for anorexia nervosa, and 12.2 per 100,000 for bulimia nervosa. The relative risks of females to males was 40:1 for anorexia nervosa and 47:1 for bulimia nervosa. A threefold increase in the recording of bulimia nervosa was found from 1988 to 1993. Eighty per cent of anorexia nervosa cases and 60% of bulimia nervosa cases were referred to secondary care. CONCLUSION: There is a continuing expansion of service need for bulimia nervosa. The majority of cases of eating disorders are referred to secondary services. There is scope for more effective management of bulimia nervosa in primary care.     

Midwifery as a discipline

BACKGROUND: The association of compulsive water drinking with bulimia nervosa is rarely encountered. Nevertheless similar behavior patterns could involve a common pathophysiological mechanism. METHODS: A case report with the association of those two disorders is described. Treatment with fluoxetine was introduced to alleviate the compulsive aspects of those disorders. RESULTS: Fluoxetine had a positive effect on bulimia nervosa but none on compulsive water drinking. CONCLUSIONS: The different response to pharmacologic treatment could mean that bulimia nervosa and compulsive water drinking are based on different physiological mechanisms.     

Leptin--missing link between the metabolic state and the reproductive system?

What is the signal between the metabolic state and reproductive function--it is one of the scientific puzzles in gynecological endocrinology. Previously it was suggested that such substances as insulin, amino acids, IGFBP-I may play a role as a metabolic signal. Leptin a newly discovered hormonal product of obesity (ob) gene is expressed by adipocytes and thought to play a role in the regulation of food intake, metabolism and reproduction. In this article some informations about leptin secretion, its regulation and localization of leptin receptors have been presented. Particular attention to leptin influence on GnRH secretion have been paid. Probably on the base of this mechanism leptin acts as a link between metabolic state and reproductive system. Some data about leptin secretion in obesity, weight loss related amenorrhoea and anorexia nervosa have been discussed. The putative role of leptin in the pathophysiology of polycystic ovary syndrome and initiation of puberty also have been analyzed.     

Reduced protein models and their application to the protein folding problem

It has been well-recognized that starvation in anorexia and bulimia nervosa causes endocrine disturbances. Such disturbances may help understand why many people with eating disorders cannot easily reverse their illness since people with eating disorders often enter a downward spiraling circle with malnutrition sustaining and perpetuating the desire for more weight loss and dieting. Symptoms, such as obsessions and dysphoric mood, and altered appetitive behavior, may be exaggerated by neuropeptide alterations and thus contribute to this downward spiral. While neuropeptide disturbances do not appear to be a permanent feature or cause or anorexia nervosa, these disturbances are strongly entrenched, and are not easily corrected by improved nutrition or short-term weight normalization. This suggests that therapy should be sustained for months after nutritional normalization.     

A study of personality in eating disorders

Some evidence suggests that temperament and personality traits could influence the development and severity of eating disorders. This study was designed to study these aspects. METHODS: 72 patients with DSM-IV eating disorders including 25 anorexia nervosa restricting type, 17 with anorexia nervosa binge eating-purging type and 30 with bulimia nervosa were studied and compared with thirty healthy controls. Personality disorders and temperament were studied with the Eysenck's EPQ, Cloninger's TCI and SCID-II. Impulsive and clinical features were studied with specific rating scales. RESULTS: 61.8% of patients had at least one personality disorder. Avoidant personality disorder was the most commonly diagnosed in anorexia restricting type (25%). Borderline personality disorder was the most frequent in bulimia nervosa and in the binge eating-purging type of anorexia nervosa. Dimensionally, the group of eating disorders presented high scores in neuroticism and low scores in self-directedness. Higher harm avoidance was found in bulimic patients and higher persistence was associated with anorectic patients. Bulimic patients were significantly more impulsive than anorectic and controls. CONCLUSIONS: Temperament and personality traits differ in anorectic and bulimic patients. Bulimic symptoms are linked to impulsive temperament traits and to impulsive personality features. Anorectic symptoms are linked to persistent temperament traits and anxious personality features.     

Males with eating disorders: challenges for treatment and research

Males represent only 10 percent of eating disorder cases. This gender discrepancy is among the most extreme in psychiatry and medicine. Determining what differences in etiology and mechanism best explain the discrepancy presents an intellectual challenge. Beginning at about the third grade, boys and girls diverge in social development. Boys show significantly less desire to lose weight, express dissatisfaction with the upper rather than the lower body, and use dieting to achieve specific external goals rather than as a cultural norm. Males reach a significantly higher body mass index (BMI) than females do before they beginning dieting. (27.2 versus 24.3, p < .01). While overall treatment principles are similar, males in treatment require attainment of a different hormonal milieu (testosterone), attention to past and future sexual role, amelioration of perception of stigma, and preparation for return to male social roles. Males and females suffer comparable degrees of osteopenia and brain shrinkage during anorexia nervosa. The effectiveness of antidepressants in males with eating disorders (compared with that in females) has not been well studied. Male gender is not an adverse factor in short-term or long-term treatment outcome. Understanding the lower frequency of these illnesses in males may lead to more effective means of protecting girls from eating disorders and from the culturally induced distress about normal body size and shape that burdens adolescent development and adult life.     

Annual treatment rates and estimated incidence of eating disorders in Austria

BACKGROUND: At present, the prevalence and incidence of eating disorders in Austria is unknown; not even rough estimates of countrywide annual treatment rates are available. AIMS: To assess the number of patients in Austria with eating disorders currently under treatment and to compare this rate with the estimated prevalence and incidence of eating disorders, thus providing an estimate of unrecorded cases and the appropriateness of health care for these disorders. METHODS: The number of patients being treated in major out-patient and in-patient facilities was assessed by questionnaires. Prevalence and incidence rates in Austria were estimated by extrapolation of epidemiological data from comparable Western countries to Austrian figures from the most recent population census in 1991. RESULTS: Altogether 1075 patients were being treated in 1994 at 26 institutions, including all specialized centres, pediatric and psychiatric university hospitals. Surprisingly, the annual treatment rates for anorexia and bulimia nervosa were equal. There is a considerable discrepancy between these treatment figures and prevalence/incidence estimates (in absolute numbers): the estimated anorexia nervosa point prevalence is about 2500 girls aged 15-20 years, whilst a minimum of 4400 girls suffer from subclinical eating disorders, and there are about 6500 bulimia nervosa cases in young women aged 20-30 years. The incidence might be about 600 new onset cases per year for anorexia, and about 870 for bulimia nervosa. The size of the problem (lifetime prevalence) may comprise at least 36,000 women with bulimia nervosa. CONCLUSIONS: Eating disorders pose a major public health problem for women in Austria. It is unlikely that the vast majority of unrecorded cases was treated in private practice or in hospitals which failed to respond to our questionnaire. The discrepancy between annual treatment rates and prevalence/incidence estimates points to a lack of specialized eating disorder units in Austria.     

Effects of DDT on reproduction in multiple generations of beagle dogs

The effects of chronic oral exposure to 1, 5, and 10 mg of technical DDT/kg/day on: 1) age at puberty, length of gestation, fertility, success of pregnancy, litter size, and lactational ability of dams; 2) viability, survival to weaning, sex distribution and growth of pups; and 3) morbidity, mortality, organ/body weight ratios, gross and histologic abnormalities in all animals were studied through three generations of Beagle dogs. There were a total of 135 adult female and 63 adult male dogs in the project which produced 650 pups. There were no statistically significant differences among control and DDT-treated dogs in any of the reproductive variables, with the exception of age at puberty of the females. DDT-treated females had their first estrous cycles 2 to 3 months earlier (P less than .001) than the control dogs. Selected DDT-treated females, held for a second breeding period, had normal anestrous periods between their first and second estrous cycles. There was no effect of DDT on survival, growth, and sex distribution of pups, nor was there any influence on morbidity, mortality, gross or histologic findings in any of the dogs. All organ/body weight ratios were normal, with the possible exception of an increase in liver/body weight ratio in some DDT-treated animals.     

Relative sedimentation of hematopoietic progenitors in human cord blood, peripheral blood, and bone marrow as determined by counterflow centrifugal elutriation

OBJECTIVE: Although there have been many studies of the outcome of anorexia nervosa, methodological weaknesses limit their interpretation. The authors used a case-control design to try to improve knowledge about the outcome of anorexia nervosa. METHOD: All new female patients referred to an eating disorders service between Jan. 1, 1981, and Dec. 31, 1984, who had probable or definite anorexia nervosa were eligible for inclusion. Of these women, 86.4% (N = 70) were located and agreed to participate. The comparison group (N = 98) was a random community sample. All subjects were interviewed with a structured diagnostic instrument. RESULTS: A minority of the patients (10%) continued to meet the criteria for anorexia nervosa a mean of 12 years after initial referral. Even among those who no longer met these criteria, relatively low body weight and cognitive features characteristic of anorexia nervosa (perfectionism and cognitive restraint) persisted. The rates of lifetime comorbid major depression, alcohol dependence, and a number of anxiety disorders were very high. CONCLUSIONS: In the managed care/brief treatment era, therapeutic approaches with an excessive focus on weight gain that neglect the detection and treatment of associated psychological features and comorbidity may be inappropriate. Anorexia nervosa is a serious psychiatric disorder with substantial morbidity.     

Male/female comparison of morphine effect on food intake--relation to anorexia nervosa

We have proposed that endogenous opioids play a critical role in the etiology of anorexia nervosa by mediating an auto-addiction. A biological predisposition may result from an atypical endogenous opioid system. Morphine activation of the system increases food intake in most species, including normal humans and rats, but decreases food intake in mice. The atypical opioid system in mice may be representative of that in anorexia nervosa patients, causing the biological predisposition. Anorexia nervosa is 10 times more prevalent in females than males. In the context of this auto-addiction opioid model, it was interesting to determine if the effects of morphine on food intake were markedly different between the two sexes. Full dose-response curves were done of the effects of morphine on food intake in males and females in both rats and mice, representing the typical and atypical responses, respectively. Differences between the sexes were not found to explain the marked prevalence of anorexia nervosa for females. The marked preference is probably at some other step.     

Internet listservers in radiology

Anorexia nervosa (AN) and bulimia nervosa (BN) are currently classified as eating disorders. Both disorders are the product of a complex interaction between psychological and physiological processes and both show considerable comorbidity with other psychiatric disorders. Physiological and endocrine abnormalities, including primary or secondary amenorrhea and menstrual dysfunction, are common and for the most part a function of the severity of weight loss, malnutrition and/or abnormal eating habits. Therefore, assessment needs to include several steps: (1) Clinical evaluation to ascertain the diagnosis, including weight and height measurements; (2) Determination of co-existing psychiatric illnesses; and (3) Physical examination and evaluation of the physiological and endocrine status. Eating disorders interfere with reproductive function. In view of the fact that dieting has reached epidemic proportions among the young female population, and given the high association between eating disorders and endocrine abnormalities as well as menstrual disturbances, all women participating in research studies should be screened for the presence of eating disorders, disordered eating, and excessive exercise.     

Biological aspects of anorexia nervosa and bulimia nervosa.

In this article, we review biological factors relevant to the understanding of anorexia nervosa and bulimia nervosa. We consider the physical presentation of these disorders; the medical complications of starvation, binging, and purging; and the cognitive and behavioral effects of starvation. We also review neurophysiological and neurochemical aspects of these illnesses and their biological treatments. These biological variables are most prominent in the perpetuation of the eating disorders. Effective treatment approaches must consider psychosocial as well as biological variables to be optimally effective. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Minimal criteria of epidemiologic studies of dental health of school children]

OBJECTIVE: To understand the developmental psychopathology of eating disorders, it is crucial to explain the large gender discrepancy in the rates of these disorders, especially anorexia nervosa and bulimia nervosa. In this paper, meta-analysis was used to examine the relationship between gender role adherence and the existence of eating problems. METHOD: Of the 69 studies examined, 22 contained data deemed valid for the analyses. Measures of difference (d) and homogeneity were calculated. These studies used the Personal Attributes Questionnaire (PAQ) or the Bem Sex Role Inventory (BSRI) to measure gender role adherence. RESULTS: Findings indicated a small, heterogeneous positive relationship between femininity and eating problems and a small, heterogeneous negative relationship between masculinity and eating problems. Studies that used a clinical sample showed a larger discrepancy in masculinity scores between the eating-disordered and the control groups than did studies using surveys to identify eating problems. Six studies measured gender role traditionalism. The eating-disordered groups did not differ significantly on these measures compared to the control groups. DISCUSSION: Despite construct validity problems with the use of the PAQ and the BSRI in this area of study, data suggest that gender role is related to eating problems. Crucial aspects of femininity likely to be related to eating problems need to be operationalized and their link to eating disorders examined.