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.     

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.     

Psychological and sexual aspects of the menopause and HRT

Despite the clinical impressions that there are considerable psychological benefits from HRT, there is only clear evidence for amelioration of psychological symptoms (including improvement in cognitive function) in women who have undergone a surgical menopause. Otherwise in the natural menopause it remains unclear which, if any, non-sexual psychological symptoms respond directly to oestrogen except as a secondary response to reduction in physical symptoms. Overall, it has to be said that there is little scientific backing for hormonal treatment of psychological problems on their own around the time of the natural menopause. In most cases psychological treatment or counselling will be more appropriate than HRT. It must be remembered that the prevalence of psychological symptoms in the menopause and gynaecology clinic is high just as it is in all hospital settings. The task is to identify which women: 1. Have a predominance of psychological symptoms and might have psychiatric disorders. They may have presented in the clinic because they also happen to be menopausal, but it may well be that the psychiatric disorder has a quite independent aetiology. They will benefit from specific treatment for that disorder. 2. Have, and complain of, low moods or other non-specific psychological symptoms and have presented in the clinic because they are menopausal. They might benefit from practical, supportive help with current and ongoing stresses and strains. 3. Present appropriate menopausal complaints and only on enquiry reveal their psychological problems. In particular, disorders such as depressive illness, anxiety states and alcohol abuse can present with physical symptoms including ones which mimic vasomotor ones. This group may well be non-responders to HRT. Women requiring particular consideration might be those with other health problems (particularly chronic ones that might carry on in to old age) who are possibly more at risk of developing depression as they pass through the menopause. There is clearer evidence that HRT has beneficial effects on sexual function. When sexual symptoms are presented it is worth clarifying the exact features contributing to the complaint. Is it a problem of sexual interest, of infrequency of sexual activity, of vaginal dryness and dyspareunia, or is it a mixture of these complaints? Reduction of sexual interest and reduced sexual activity with the partner and possibly orgasm may accompany the menopause. Oestrogens have been shown to have some beneficial effect on sexual desire. Where oestrogen alone is ineffective, testosterone is usually beneficial. This treatment effect is particularly clear in surgically menopausal women. Non-menopausal aspects of the sexual relationship must be considered too. These aspects include the quality of the relationship, the sexual performance of the partner (since sexual desire decreases in both sexes with age), and age-related changes in self-image. These issues may need to be addressed at a simple health education level or with specific counselling. Although a woman's motivation or desire might change as a result of HRT, on its own this will not influence the frequency of intercourse or response during intercourse unless the partner variables permit this. The situation is more straightforward when problems of postmenopausal vaginal dryness and dyspareunia are the key issues. Oestrogens have been shown to be highly effective in such circumstances. It is also worth noting that regular and continued sexual activity has been found to protect against vaginal dryness.     

Males and eating disorders: Gender-based therapy for eating disorder recovery.

Mental health professionals may wonder how males with eating disorders differ from females with eating disorders and how best to treat males with eating disorders. The eating disorder literature largely focuses on females. Limited research has examined assessment and treatment of eating disorders in males. This article offers a unique view of eating disorder treatment for males by integrating it with the literature on the psychology of men. Mental health professionals are given practical suggestions to guide eating disorder recovery in males. A case example shows treatment considerations for working with males with disordered eating behaviors. (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.     

Eating disorders in males: a report on 135 patients

OBJECTIVE: The goal of this study was to better understand the etiology, clinical characteristics, and prognosis of eating disorders in males. METHOD: All males with eating disorders who had been treated at Massachusetts General Hospital from Jan. 1, 1980, to Dec. 31, 1994, were identified. Hospital charts and psychiatric departmental records were reviewed to verify that the eating disorders met DSM-IV criteria and to abstract demographic and clinical data. RESULTS: One hundred thirty-five males with eating disorders were identified, of whom 62 (46%) were bulimic, 30 (22%) were anorexic, and 43 (32%) met criteria for an eating disorder not otherwise specified. There were marked differences in sexual orientation by diagnostic group; 42% of the male bulimic patients were identified as either homosexual or bisexual, and 58% of the anorexic patients were identified as asexual. Comorbid psychiatric disorders were common, particularly major depressive disorder (54% of all patients), substance abuse (37%), and personality disorder (26%). Many patients had a family history of affective disorder (29%) or alcoholism (37%). CONCLUSIONS: While most characteristics of males and females with eating disorders are similar, homosexuality/bisexuality appears to be a specific risk factor for males, especially for those who develop bulimia nervosa. Future research on the link between sexual orientation and eating disorders would help guide prevention and treatment strategies.     

Childhood abuse, body image disturbance, and eating disorders

Studies have suggested that women who experience child sexual abuse are at risk for developing symptoms related to anorexia nervosa and bulimia. The purpose of the present study was to examine the relationships among childhood sexual and physical abuse, body image disturbance, and eating disorder symptomatology. Of 670 female college students screened for childhood abuse, 29 sexually abused, 32 physically abused, and 29 nonabused women completed measures of eating disorder symptoms, psychological factors thought to be related to eating disorders, and body image distortion. Contrary to previous reports, there was no evidence that child sexual or physical abuse was associated with the development of body image disturbance. Furthermore, the results did not support the hypothesis that child sexual and physical abuse are related to eating disorder symptomatology. It is suggested that subjects who are victims of child sexual abuse and who are receiving psychotherapy manifest higher rates of a number of different types of psychopathology, including eating disorders.     

An appraisal of the relationship between women and psychotherapy: 80 years after the case of Dora.

Reviews concerns that have turned women away from psychotherapy, specifically sex bias and inadequate responses to the special problems of women. The pervasive unhappiness of many women has become a subject for psychotherapy, yet clinical theories of development have been inadequate in terms of women's experience. Freud's theories and those of his followers are based on men's development and on the anatomical differences between the sexes, with women designated as biologically inferior. Freud's case of Dora demonstrates his prejudicial theory. Little attention has been given to the fact that women experience dramatic and unique bodily changes in the course of their lives. Such theories and biases have led to sex-role bias and sex-role stereotyping by therapists. Studies have shown that women may be treated by therapists with more potent medications and for a longer period than men with the same ailment; women are also more likely to be treated as sex objects. Psychological problems that have a higher prevalence in women than men have not received appropriate attention; these include problems of marital and family relations, reproductive problems, physical and sexual abuse, depression, and problems associated with eating. Pathological labels have often been assigned to women for conditions that may be caused by environmental stress or that result from prolonged powerlessness or women's socialization. (84 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Are two interventions worse than none? Joint primary and secondary prevention of eating disorders in college females.

Prevention programs for eating disorders attempt to simultaneously prevent new cases from arising (primary prevention) and encourage students who already have symptoms to seek early treatment (secondary prevention), even though ideal strategies for these 2 types of prevention may be incompatible with each other. In the present study, an eating disorder prevention program was evaluated in a sample of female college freshmen. In the intervention, classmates who had recovered from eating disorders described their experiences and provided information about eating disorders. At follow-up, intervention participants had slightly more symptoms of eating disorders than did controls. The program may have been ineffective in preventing eating disorders because by reducing the stigma of these disorders (to encourage students with problems to seek help), the program may have inadvertently normalized them. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of SSRIs on sexual function: a critical review

Sexual problems are highly prevalent in both men and women and are affected by, among other factors, mood state, interpersonal functioning, and psychotropic medications. The incidence of antidepressant-induced sexual dysfunction is difficult to estimate because of the potentially confounding effects of the illness itself, social and interpersonal comorbidities, medication effects, and design and assessment problems in most studies. Estimates of sexual dysfunction vary from a small percentage to more than 80%. This article reviews current evidence regarding sexual side effects of selective serotonin reuptake inhibitors (SSRIs). Among the sexual side effects most commonly associated with SSRIs are delayed ejaculation and absent or delayed orgasm. Sexual desire (libido) and arousal difficulties are also frequently reported, although the specific association of these disorders to SSRI use has not been consistently shown. The effects of SSRIs on sexual functioning seem strongly dose-related and may vary among the group according to serotonin and dopamine reuptake mechanisms, induction of prolactin release, anticholinergic effects, inhibition of nitric oxide synthetase, and propensity for accumulation over time. A variety of strategies have been reported in the management of SSRI-induced sexual dysfunction, including waiting for tolerance to develop, dosage reduction, drug holidays, substitution of another antidepressant drug, and various augmentation strategies with 5-hydroxytryptamine-2 (5-HT2), 5-HT3, and alpha2 adrenergic receptor antagonists, 5-HT1A and dopamine receptor agonists, and phosphodiesterase (PDE5) enzyme inhibitors. Sexual side effects of SSRIs should not be viewed as entirely negative; some studies have shown improved control of premature ejaculation in men. The impacts of sexual side effects of SSRIs on treatment compliance and on patients' quality of life are important clinical considerations.     

Food preferences, eating patterns, and physical activity among adolescents: correlates of eating disorders symptoms

PURPOSE: Food preferences, eating patterns, and physical activity patterns were examined in a cohort of adolescent females and males participating in a longitudinal study of the developmental antecedents of eating disorders. METHODS: All adolescents (n = 1494) in grades seven through ten in an entire school district completed a survey about their dieting behaviors, eating, and exercise patterns. RESULTS: Principal components analysis showed similar factor structures for food preferences and eating patterns among males and females. Gender differences were present in physical activity patterns. Sports participation was correlated with healthy food preference and was a significant predictor of eating disorders symptoms. Junk food preference was marginally inversely related to eating disorders symptoms in females. Preference for other types of foods and reported intake of foods were not related to eating disorders symptoms. The percent of variance in risk score accounted for by dietary intake and physical activity patterns was small. CONCLUSIONS: Psychological and social/environmental variables may explain a larger proportion of the variance in eating disorders risk than the dietary and physical activity variables examined in this study. Implications for understanding the etiology and behavioral expression of eating disorders are discussed.     

Health for all: analyzing health status and determinants

Several clinical disorders are strongly influenced by hormones involved in appetite and weight regulation. Obesity and eating disorders are of major importance, because they are associated with severe morbidity and considered to be among the greatest health problems in the Western world today. This review describes recent findings in hormonal regulation of food intake by substances acting both centrally, such as corticotropin-releasing factor, neuropeptide Y and leptin, and peripherally, such as cholecystokinin and somatostatin. Sex hormones and glucocorticoids play an important role in long-term regulation of metabolism. The role of these hormones in appetite and weight changes during life as well as during pregnancy and lactation is discussed. Furthermore, the development of obesity and eating disorders is influenced, in particular, by steroid hormones. Treatment with sex hormones, as in hormone replacement therapy, affects appetite and weight and may have beneficial effects in preventing android obesity. Currently, there is great effort in developing endogenous neurohumoral substances into effective drugs for the treatment of obesity and eating disorders. Leptin and neuropeptide Y analogues are of interest as potential antiobesity agents.     

Development of eating problems in adolescent girls: A longitudinal study.

Examined the emergence of eating problems in adolescent girls as a function of pubertal growth, body image, personality development, and family relationships. 193 White females and their mothers were seen in middle-school years (M age?=?13.93 years) and 2 years later. Results showed that girls who early in adolescence felt most negatively about their bodies were more likely to develop eating problems (on EAT-26) 2 years later. Concurrently, Time 1 eating problems were associated with body fat, grade, negative body image, and psychopathology, but not family relationships. At Time 2, adolescent body image and internalizing dimensions of psychopathology predicted problem-eating scores, as did maternal body image and depression. Findings are discussed in terms of adolescent patterns of adaptation, developmental psychopathology, and the study's relevance for understanding clinical eating disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Revisiting the latent structure of eating disorders: Taxometric analyses with nonbehavioral indicators.

Researchers have debated whether clinical eating disorders are best conceptualized as one extreme along a continuum of degree or as qualitatively different from less severe eating disturbances. Taxometric analysis, a set of procedures that assess the structure of a given disorder by detecting whether a latent taxon exists among its indicators, has just begun to be applied to eating disorder research. Its application to this domain may clarify whether eating disorders best conform to a dimensional (i.e.. continuum) or taxonic model. The latent structure of eating disorders was examined in a sample of 532 college women by using 2 popular taxometric procedures (i.e., maximum covariance analysis and latent mode analysis) with 5 nonbehavioral indicators of eating disorder symptomatology. Results across procedures suggest that the data are more indicative of a dimensional solution, as no latent taxon was uncovered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Eating, weight, and dieting disturbances in male and female lightweight and heavyweight rowers

Rowers compete in a sport that allows comparison of male and female athletes and where some (lightweight) but not others (heavyweights) must meet specific weight criteria. Eating attitudes, dieting patterns, weight fluctuation, and methods of weight loss were evaluated in 162 rowers: 82 heavyweights (56 females, 26 males) and 80 lightweights (17 females, 63 males). Females displayed more disturbed eating practices and weight control methods than did males. Lightweights did not have more disturbed eating practices than heavyweights, but employed more extreme weight loss methods. Male rowers were more affected by weight restriction than were female rowers. Lightweight males showed greater weight fluctuation during the season and gained more weight during the offseason than did lightweight females and heavyweight males and females. These results indicate that rowing can join the growing list of sports where eating and weight disturbances may be present. Male athletes may be more vulnerable to these problems than previously recognized.     

Are you treating youngsters who are or should be receiving mental health services?

Psychiatrists now recognize that the disorders of children are serious, treatable conditions and as precursors of adult psychopathology. These conditions can seriously influence the patient's behavior when undergoing dental treatment. The dentist will probably assume that the behavior problems are directly related to the nature of the dental service, rather than particular underlying personality characteristics of preschool and school-age children. It is important that practitioners recognize and understand these conditions as they attempt to provide adequate treatment. No national epidemiological studies have been conducted in this country that would provide valid indicators of either the prevalence or incidence of mental disorders among children. Local studies, however, have been done that diagnosable disorders in children range from 17.6 percent to 22 percent, including 3 percent to 5 percent who have severe emotional or behavioral problems. The prevalence of many mental disorders is greater in males than in females, ranging from a ratio of 2:1 to 9:1. Lifetime prevalence of mental disorders, first diagnosed in infancy, childhood, and adolescence range as high as 15,000 cases per 100,000 persons. It is important for the dentist to recognize that (1) even the youngest of children seen in a dental practice may be in need of mental health services, (2) management problems may stem from mental health problems, and (3) families are unaware or unwilling to admit that a child may need help.     

Middle-ear impedance measurements in screening

Middle-ear disorders are the major cause of hearing loss in the young school child, the majority of sensorineural disorders already having been detected. Mild conductive deafness may lead to educational retardation, psychological and social problems as well as to more severe middle-ear problems. It is consequently important to detect persistent middle-ear conditions as early as possible. Pure-tone audiometry has been shown to be a poor method of identifying middle-ear effusions. Impedance measurement is considerably more efficient, and different approaches are reviewed in the light of long-term studies of middle-ear effusion.     

Psychiatric disorders associated with risk for the development of eating disorders during adolescence and early adulthood.

Longitudinal data were used to investigate whether anxiety, depressive, disruptive, personality, or substance use disorders are associated with risk for the development of eating disorders during adolescence or early adulthood. Psychiatric disorders were assessed among 726 youths from a random community sample during adolescence and early adulthood. Depressive disorders during early adolescence were associated with elevated risk for the onset of eating disorders, dietary restriction, purging behavior, and recurrent weight fluctuations after preexisting eating problems and other psychiatric disorders were controlled statistically. Disruptive and personality disorders were independently associated with elevated risk for specific eating or weight problems. The present findings suggest that depressive disorders during early adolescence may contribute to the development of eating disorders during middle adolescence or early adulthood. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Body image disturbance in body dysmorphic disorder and eating disorders. Obsessions or delusions?

At this time, the question posed by this article's title--body image disturbance in body dysmorphic disorder and eating disorders: obsessions or delusions?--is probably best answered "both." Both disorders appear to be characterized by obsessional and delusional thinking. In addition, it is likely that their nondelusional and delusional variants constitute a single disorder encompassing a spectrum of insight, with the entire spectrum characterized by obsessional thinking. This view represents a considerable departure from DSM-III-R, in which the psychotic disorders were encapsulated in a separate section of the manual and considered different disorders from their nonpsychotic variants. The one exception was the mood disorders, which were acknowledged to have psychotic variants that were classified in the manual's "nonpsychotic" section. In DSM-IV, on the basis of emerging empirical evidence about the dimensional nature of the psychotic/nonpsychotic boundary, the dichotomy between delusional and nondelusional disorders is less clear. The double coding allowed for BDD acknowledges that BDD and its delusional disorder variant may constitute a single disorder; that allowed for OCD acknowledges that OCD may be delusional. With regard to eating disorders, however, DSM-IV is surprisingly silent, perhaps because delusional preoccupations are less common than in BDD. These issues also may apply to other disorders. Like BDD, hypochondriasis is classified as a somatoform disorder, with its delusional variant a type of delusional disorder, somatic type. Do the delusional and nondelusional variants of hypochondriasis constitute the same disorder? Do other types of somatic delusional disorder, such as parasitosis and olfactory reference syndrome (the belief that one emits a foul body odor) have nondelusional variants? It is likely that a number of disorders span a spectrum from delusional to nondelusional thinking, with unlimited shades of gray in between. Future research may indicate that obsessional disorders such as BDD, anorexia, OCD, and hypochondriasis, as well as other disorders such as major depression, should have qualifiers or subtypes--for example, "with good insight," "with poor insight," and "with delusional (or psychotic) thinking"--with an implied continuum of insight embraced by a single disorder. Such an approach, which scatters psychosis throughout the nomenclature, ultimately may be shown to be a more valid and clinically useful classification approach. Answers to these questions will not only improve our classification system but also may have important treatment implications. For example, the preliminary finding that delusional BDD responds preferentially to SRIs but not to neuroleptic agents contradicts conventional wisdom about the treatment of psychosis.(ABSTRACT TRUNCATED AT 400 WORDS)