Eating disorders in the DSM-IV..

The guiding principles and operating procedures of the Eating Disorders Work Group are described. Provisional diagnostic criteria for the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) for anorexia nervosa and bulimia nervosa are listed, together with an explanation of how and why they differ from the revised 3rd edition (DSM-III—R; American Psychiatric Association, 1987). Consideration of a possible new diagnosis is noted. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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.     

Diagnosis and treatment of anorexia nervosa

Anorexia nervosa is much like other psychogenic or psychosomatic disorders in that it tends to run a chronic, relapsing course, with a proportion of patients never fully recovering. It is unlike them, however, in that significant mortality rates have been reported. With epidemiological studies now suggesting an increased incidence of the disorder, and follow-up studies indicating the importance of early treatment to favorable outcome, the vital role of family physicians in diagnosis and treatment becomes evident. This paper draws on both published accounts and original case material to summarize the primary diagnostic criteria and secondary signs of anorexia nervosa. An illustrative history of a young woman with chronic anorexia nervosa is followed by a discussion of treatment alternatives. Although still in the experimental stage, behavior therapy is presented for its apparent efficacy and adaptability to the outpatient family practice setting.     

Overvaluation of shape and weight in binge eating disorder and overweight controls: Refinement of a diagnostic construct.

Debate continues regarding the nosological status of binge eating disorder (BED) as a diagnosis as opposed to simply reflecting a useful marker for psychopathology. Contention also exists regarding the specific criteria for the BED diagnosis, including whether, like anorexia nervosa and bulimia nervosa, it should be characterized by overvaluation of shape/weight. The authors compared features of eating disorders, psychological distress, and weight among overweight BED participants who overvalue their shape/weight (n = 92), BED participants with subclinical levels of overvaluation (n = 73), and participants in an overweight comparison group without BED (n = 45). BED participants categorized with clinical overvaluation reported greater eating-related psychopathology and depression levels than those with subclinical overvaluation. Both BED groups reported greater overall eating pathology and depression levels than the overweight comparison group. Group differences existed despite similar levels of overweight across the 3 groups, as well as when controlling for group differences in depression levels. These findings provide further support for the research diagnostic construct and make a case for the importance of shape/weight overvaluation as a diagnostic specifier. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Multifactorial assessment of bulimia nervosa.

Investigated a multifactorial approach to the assessment of bulimia nervosa by means of hierarchical factor analysis. 245 bulimia nervosa patients and 68 patients with either anorexia nervosa or eating disorders not otherwise specified were administered a self-report battery that was organized into 21 dimensions relevant to eating disorder patients. When dimensions from this battery were subjected to hierarchical factor analysis, support for bulimia nervosa as a unique diagnostic category was obtained. However, the emergence of 3 secondary factors and 6 primary factors suggests that bulimia nervosa can also be described more complexly. The emergence of a multifactorial model of bulimia nervosa that incorporates several existing unidimensional models suggests the potential for both divergent and complicated clinical presentation in bulimia nervosa patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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.     

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.     

The Bulimia Test—Revised: Validation with DSM-IV criteria for bulimia nervosa.

The Bulimia Test —Revised [(BULIT-R) M. H. Thelen, J. Farmer, S. Wonderlich, & M. Smith; see record 78:17280] was given to participants who met the criteria in the fourth edition of the Diagnostic and Siatistical Manual of Mental Disorders (DSM-IV) for bulimia nervosa and control participants to determine if the test continues to be a valid measure of bulimia nervosa. Although the BULIT-R was developed and validated with bulimic individuals as determined by the DSM-III-R criteria, it appears to be a valid instrument with which to identify individuals who meet DSM-IVcriteria for bulimia nervosa. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Development and validation of a test for bulimia.

Describes the development of a bulimia test (BULIT), a 32-item, self-report, multiple-choice scale that assesses symptoms of bulimia for clinical work and research. The BULIT was constructed by comparing responses of clinically identified female bulimic Ss with normal female college students on 75 preliminary test items, which were based on DSM-III criteria for bulimia. Cross-validation was performed on independent samples of bulimic and control Ss. The BULIT was a good predictor of group membership for both initial and replication samples. The scale was then administered to female college students, and a stratified sample of these Ss was retested and interviewed several weeks later. Results of retesting and judgments of diagnostic interviews show that the BULIT is a reliable and valid predictor of bulimia in a nonclinical population. The BULIT correlated highly with another measure of bulimia, indicating a high degree of construct validity. A lower correlation with a measure of anorexia nervosa suggests that bulimia and anorexia nervosa represent overlapping, but not identical, syndromes. The BULIT is appended. (10 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The relationship between eating disorder not otherwise specified (EDNOS) and officially recognized eating disorders: Meta-analysis and implications for DSM.

Eating disorder not otherwise specified (EDNOS) is the most prevalent eating disorder (ED) diagnosis. In this meta-analysis, the authors aimed to inform Diagnostic and Statistical Manual of Mental Disorders revisions by comparing the psychopathology of EDNOS with that of the officially recognized EDs: anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). A comprehensive literature search identified 125 eligible studies (published and unpublished) appearing in the literature from 1987 to 2007. Random effects analyses indicated that whereas EDNOS did not differ significantly from AN and BED on eating pathology or general psychopathology, BN exhibited greater eating and general psychopathology than EDNOS. Moderator analyses indicated that EDNOS groups who met all diagnostic criteria for AN except for amenorrhea did not differ significantly from full syndrome cases. Similarly, EDNOS groups who met all criteria for BN or BED except for binge frequency did not differ significantly from full syndrome cases. Results suggest that EDNOS represents a set of disorders associated with substantial psychological and physiological morbidity. Although certain EDNOS subtypes could be incorporated into existing Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) categories, others—such as purging disorder and non-fat-phobic AN—may be best conceptualized as distinct syndromes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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.     

An 8-year longitudinal study of the natural history of threshold, subthreshold, and partial eating disorders from a community sample of adolescents.

The authors examined the natural history of threshold, subthreshold, and partial eating disorders in a community sample of 496 adolescent girls who completed annual diagnostic interviews over an 8-year period. Lifetime prevalence by age 20 years was 0.6% and 0.6% for threshold and subthreshold anorexia nervosa (AN), 1.6% and 6.1% for threshold and subthreshold bulimia nervosa (BN), 1.0% and 4.6% for threshold and subthreshold binge-eating disorder (BED), and 4.4% for purging disorder (PD). Overall, 12% of adolescents experienced some form of eating disorder. Subthreshold BN and BED and threshold PD were associated with elevated treatment, impairment, and distress. Peak age of onset was 17–18 years for BN and BED and 18–20 years for PD. Average episode duration in months was 3.9 for BN and BED and 5.1 for PD. One-year recovery rates ranged from 91% to 96%. Relapse rates were 41% for BN, 33% for BED, and 5% for PD. For BN and BED, subthreshold cases often progressed to threshold cases and diagnostic crossover was most likely for these disorders. Results suggest that subthreshold eating disorders are more prevalent than threshold eating disorders and are associated with marked impairment. (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.     

A randomized controlled trial of guided imagery in bulimia nervosa

BACKGROUND: The objective of this study was to test a guided imagery therapy designed to enhance self-comforting in bulimia nervosa. METHODS: A randomized controlled trial compared 6 weeks of individual guided imagery therapy with a control group. Fifty participants who met DSM-III-R criteria for bulimia nervosa completed the study. Measures of eating disorder symptoms, psychological functioning and the experience of guided imagery therapy were administered. RESULTS: The guided imagery treatment had substantial effects on the reduction of bingeing and purging episodes; the imagery group had a mean reduction of binges of 74% and of vomiting of 73%. The imagery treatment also demonstrated improvement on measures of attitudes concerning eating, dieting and body weight in comparison to the control group. In addition, the guided imagery demonstrated improvement on psychological measures of aloneness and the ability for self-comforting. CONCLUSIONS: Evidence from this study suggests that guided imagery was an effective treatment for bulimia nervosa, at least in the short-term.     

Cognitive behavioral guided self-help for the treatment of recurrent binge eating.

Objective: Despite proven efficacy of cognitive behavioral therapy (CBT) for treating eating disorders with binge eating as the core symptom, few patients receive CBT in clinical practice. Our blended efficacy–effectiveness study sought to evaluate whether a manual-based guided self-help form of CBT (CBT-GSH), delivered in 8 sessions in a health maintenance organization setting over a 12-week period by master's-level interventionists, is more effective than treatment as usual (TAU). Method: In all, 123 individuals (mean age = 37.2; 91.9% female, 96.7% non-Hispanic White) were randomized, including 10.6% with bulimia nervosa (BN), 48% with binge eating disorder (BED), and 41.4% with recurrent binge eating in the absence of BN or BED. Baseline, posttreatment, and 6- and 12-month follow-up data were used in intent-to-treat analyses. Results: At 12-month follow-up, CBT-GSH resulted in greater abstinence from binge eating (64.2%) than TAU (44.6%; number needed to treat = 5), as measured by the Eating Disorder Examination (EDE). Secondary outcomes reflected greater improvements in the CBT-GSH group in dietary restraint (d = 0.30); eating, shape, and weight concern (ds = 0.54, 1.01, 0.49, respectively; measured by the EDE Questionnaire); depression (d = 0.56; Beck Depression Inventory); and social adjustment (d = 0.58; Work and Social Adjustment Scale), but not weight change. Conclusions: CBT-GSH is a viable first-line treatment option for the majority of patients with recurrent binge eating who do not meet diagnostic criteria for BN or anorexia nervosa. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sex bias in the diagnosis of personality disorders: An evaluation of DSM-IV criteria.

This study considered whether the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) is biased against women by requiring less dysfunction for the personality disorders that are more commonly diagnosed in women (e.g., histrionic). Clinicians estimated the extent of social dysfunction, occupational dysfunction, and personal distress suggested by each of the diagnostic criteria for 6 personality disorders. The results failed to suggest a bias against women, as there was no difference in the overall level of dysfunction associated with the female-typed personality disorder diagnostic criteria (fewer criteria are also required for the male-typed diagnoses). However, the considerable variation in dysfunction across disorders and criteria, and the minimal degree of impairment implied by some of the diagnostic criteria, also raise more general issues that should perhaps be addressed in future editions of the diagnostic manual. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sex bias in the diagnosis of histrionic and antisocial personality disorders.

The differential prevalence of the histrionic and antisocial personality disorders among men and women has been attributed both to sex biases and to actual variation in disorder base rates. The present study assessed the bias and base rate explanations and examined whether sex biases are minimized by the relatively explicit diagnostic criteria in the DSM-III. Psychologists (N?=?354) either diagnosed 9 DSM-III disorders from case histories that varied in the ambiguity of the antisocial and histrionic personality disorder diagnoses or rated the degree to which specific features extracted from the case histories met 10 histrionic and antisocial diagnostic criteria. The sex of the patient was either male, female, or unspecified. Sex biases were evident for the diagnoses but not for the diagnostic criteria. The results are discussed with respect to base rate effects, sex biases, and the construction of diagnostic criteria. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Is amenorrhea a critical criterion for anorexia nervosa?

The significance of amenorrhea as a criterion for anorexia nervosa was examined. Twelve nonamenorrheic women treated for anorexia were compared with 40 women meeting full DSM-IV criteria. The nonamenorrheic group displayed the same high levels of eating disorder, body-image disturbance, and psychopathology as the amenorrheic group, as measured by the following variables: body-size overestimation on the Image Marking Procedure; body distortion on the Body Distortion Questionnaire; eating disorder on the Eating Disorder Inventory; depression on the Beck Depression Inventory; psychopathology on the MMPI; and external locus of control on the Rotter Locus of Control Scale. Amenorrhea does not appear to be a useful criterion for distinguishing full-syndrome anorexia nervosa from partial-syndrome cases.     

Physiological effects of bulimia nervosa on the gastrointestinal tract

Bulimia nervosa is an eating disorder characterized by frequent bouts of binge eating accompanied by compensatory behaviour for preventing weight gain (purging). It is estimated that 3% to 5% of young women are affected by bulimia nervosa, and its prevalence is increasing. Bulimia nervosa afflicts both sexes and all races. It can lead to serious medical complications. The expression of the disease in the gastrointestinal tract may have a critical role in the diagnosis of bulimia nervosa. Physiological effects of bulimia nervosa on the gastrointestinal tract include dental caries and enamel erosion; enlargement of the parotid gland; esophagitis; changes in gastric capacity and gastric emptying; gastric necrosis; and alterations of the intestinal mucosa. Identification of any of these factors may aid in establishing an early diagnosis, which has been shown to increase the likelihood of recovery.