Assessing quality of life in eating disorder patients.

OBJECTIVE: To examine quality of life among subgroups of eating disorder patients. METHOD: Self-report questionnaires which included two quality of life measures were completed by 87 individuals referred for treatment to the Australian Capital Territory Eating Disorders Day Program. Health-related quality of life, as measured by the Medical Outcomes Study 12-item Short Form Mental Component Summary scale, and subjective quality of life, as measured by subscales of the World Health Organization Brief Quality of Life Assessment Scale (WHOQOL-BREF), were compared among individuals who received the diagnosis of anorexia nervosa purging subtype (n = 15), anorexia nervosa restricting subtype (n = 19), bulimia nervosa (n = 40) and binge eating disorder (n = 10), and among a general population sample of young adult women employed as a control group (n = 495). RESULTS: Eating disorder patients, when considered together, showed marked impairment in both health-related and subjective quality of life relative to normal control subjects. However, in both domains, restricting anorexia nervosa patients reported significantly better quality of life than other patient groups, after controlling for levels of general psychological distress. Scores on the Social Relationships subscale of the WHOQOL-BREF among individuals in this subgroup were similar to those of normal control subjects. CONCLUSIONS: Reliance on any one instrument is likely to be misleading in assessing the quality of life of eating disorder patients. Careful consideration needs to be given to the assessment of restricting anorexia nervosa patients in particular.

Mode of delivery, but not questionnaire length, affected response in an epidemiological study of eating-disordered behavior.

BACKGROUND AND OBJECTIVES: The effects of questionnaire length and mode of delivery on response rates were examined in an epidemiological study of eating-disordered behavior. METHODS: Short (8 pages) and long (14 pages) questionnaires were posted or hand-delivered to a community sample of 802 women. Nonrespondents who received the first questionnaire by hand delivery received a reminder letter and replacement questionnaire by post; those who received the initial questionnaire by post were further randomized to receive the first reminder by hand delivery or by post, in short or long form. A second reminder letter and questionnaire (in short or long form) were posted to all remaining nonrespondents. RESULTS: The overall response rate was 52.9%. This is a conservative estimate of true response, because in a substantial proportion of cases (12.2%) individuals were no longer resident at the listed address. There was a significant effect of mode of delivery on response, favoring hand delivery, at both the initial mailout and first reminder. There was no effect of questionnaire length on response to the initial mailout, although overall response was significantly higher for the longer form. It was estimated that an overall response of 58.0% would have been achieved had first reminders been hand-delivered to all nonrespondents who received the initial mailout by post. CONCLUSIONS: Delivery of questionnaires by hand may be an effective way to increase response rates in epidemiological research, but little is to be gained by reducing questionnaire length.

Beliefs of women concerning the severity and prevalence of bulimia nervosa.

BACKGROUND: Few studies have examined attitudes towards eating-disordered behaviour among women in the general population. METHODS: A vignette describing a fictional person meeting diagnostic criteria for bulimia nervosa (BN) was presented to a community sample of women aged 18-45. Respondents (n = 208) were asked a series of questions concerning the severity and prevalence of the problem described. RESULTS: Most respondents viewed BN as a distressing condition whose sufferers are deserving of sympathy. However, more than one-third of respondents had at some stage believed that it 'might not be too bad' to be like the person described in the vignette. Most respondents believed that the prevalence of the problem described among women in the community was likely to be between 10 % and 30 % (48.6%) or between 30% and 50 % (23.1 %). Individuals with a clinically significant eating disorder (n = 13, 6.3%) were more likely to perceive the symptoms of BN as being acceptable, and its prevalence higher, than individuals with no eating disorder diagnosis. CONCLUSIONS: Information concerning the medical and psychological sequelae of BN and other eating disorders might usefully be incorporated in prevention programmes. Prospective community-based research is required to elucidate the nature of the relationship between perceived acceptability of eating disorder symptoms and actual eating disorder psychopathology. Extension of the present research to examine the views of women in other cultures would also be of interest.

Validity of the Eating Disorder Examination Questionnaire (EDE-Q) in screening for eating disorders in community samples.

In order to examine the concurrent and criterion validity of the questionnaire version of the Eating Disorders Examination (EDE-Q), self-report and interview formats were administered to a community sample of women aged 18-45 (n = 208). Correlations between EDE-Q and EDE subscales ranged from 0.68 for Eating Concern to 0.78 for Shape Concern. Scores on the EDE-Q were significantly higher than those of the EDE for all subscales, with the mean difference ranging from 0.25 for Restraint to 0.85 for Shape Concern. Frequency of both objective bulimic episodes (OBEs) and subjective bulimic episodes (SBEs) was significantly correlated between measures. Chance-corrected agreement between EDE-Q and EDE ratings of the presence of OBEs was fair, while that for SBEs was poor. Receiver operating characteristic (ROC) analysis, based on a sample of 13 cases, indicated that a score of 2.3 on the global scale of the EDE-Q in conjunction with the occurrence of any OBEs and/or use of exercise as a means of weight control, yielded optimal validity coefficients (sensitivity = 0.83, specificity = 0.96, positive predictive value = 0.56). A stepwise discriminant function analysis yielded eight EDE-Q items which best distinguished cases from non-cases, including frequency of OBEs, use of exercise as a means of weight control, use of self-induced vomiting, use of laxatives and guilt about eating. The EDE-Q has good concurrent validity and acceptable criterion validity. The measure appears well-suited to use in prospective epidemiological studies.

Osteoporosis in eating disorders: a follow-up study of patients with anorexia and bulimia nervosa.

This study prospectively investigated the course of bone mineral density (BMD) in patients with anorexia nervosa (AN) and bulimia nervosa (BN) over a 3.6-yr follow-up period. From an initial sample of 47 female patients with an eating disorder (T1), 38 (n = 24 AN; n = 14 BN) were reassessed at follow-up (T2) (participation rate, 80.1%). For nonrecovered AN patients at T2, prevalence rates of osteopenia (-1.0 SD > or = T-score > -2.5 SD) and osteoporosis (T-score < or = -2.5 SD) at the lumbar spine were 54.2 and 20.8%, respectively. Due to an annual loss of lumbar spine BMD (-3.7 +/- 4.9%) in the chronic AN patients and a slight but insignificant annual increase (0.7 +/- 1.7%) for those who recovered, the difference in BMD between both outcome groups was more pronounced at follow-up (0.93 +/- 0.13 vs. 1.14 +/- 0.13 g/cm2; P < 0.01). Nonrecovered AN patients with binge eating/purging type showed a significantly reduced BMD compared with patients with the restricting type (0.87 +/- 0.13 vs. 1.02 +/- 0.08 g/cm2; P = 0.02). Both at baseline and follow-up, AN patients had increased rates of bone resorption, as measured by urinary desoxypyridinoline, compared with a control group (n = 42) (11.4 +/- 4.4 vs. 10.4 +/- 7.8, P < 0.001, vs. 5.6 +/- 2.4 and 10.4 +/- 7.8 nM/mM creatinine, P < 0.05, respectively). The subtype of AN and body mass index were best predictors for BMD at the lumbar spine at follow-up (R2 = 0.576). With one exception, all bulimic patients had BMD and markers of bone turnover within the normal range. These results suggest that patients with chronic AN, particularly of the binge eating/purging type, are at high risk for osteoporosis and may need additional therapy to prevent bone loss.

Cross-Cultural Research on Anorexia Nervosa: Assumptions Regarding the Role of Body Weight.

OBJECTIVE: To critically examine two assumptions guiding cross-cultural research on the weight concerns of anorexia nervosa: (1) that weight concerns are specific to contemporary, Western manifestations of the disorder and (2) that the dissemination of Western values regarding thinness is primarily responsible for the development of anorexia nervosa in non-Western contexts. METHOD: A review of theoretical and empirical literature on cross-cultural aspects of anorexia nervosa and the medical records of 14 Asian patients treated for eating disorders in Sydney, Australia. RESULTS AND DISCUSSION: Regarding the first assumption: It is argued that weight concerns when defined as weight loss that is positively valued (rather than a fat phobia) is a defining characteristic of anorexia nervosa and is not limited to contemporary, Western cases of the disorder. Regarding the second assumption: It is argued that the occurrence of anorexia nervosa in non-Western contexts cannot be solely attributed to the acceptance of Western thinness ideals because values and practices intrinsic to non-Western cultures are also likely to be etiologically relevant.

Altered energy metabolism in anorexia nervosa.

Optimal nutritional rehabilitation of anorexia nervosa requires more information concerning actual energy and substrate requirements. To this end, indirect calorimetry was performed in female patients (n=34, age 20.9+/-1.2 yr, body mass index [BMI] 15.6+/-0.2 kg/m(2); mean+/-SEM) soon after commencement of refeeding and at the time of discharge from hospital (n=18, BMI 19.0+/-0.3 kg/m(2)). Healthy female controls (n=18, age 24.6+/-1.3 yr, BMI 21.6+/-0.6 kg/m(2)) were also tested. Resting energy expenditure (REE) and respiratory quotient (RQ) were measured in the fasting state, followed by diet-induced thermogenesis (DIT) and RQ over a 4 h period following a 100 g oral glucose load. Compared with post-refeeding patients and controls, pre-refeeding patients had a high basal RQ and a low REE, with a paradoxically higher DIT (13.2+/-0.9% of REE vs. 8.3+/-1.2% and 8.6+/-0.9% in post-refeeding patients and controls, respectively). RQ values in pre-refeeding patients exceeded unity following the glucose load, probably reflecting net lipogenesis, whereas in the post-refeeding patients, post-glucose RQ was similar to that of controls, suggesting premature curtailment of lipogenesis. These data demonstrate energy wasting in emaciated patients with anorexia nervosa. Biological repair processes could account for disproportionate energy loss early in refeeding and there may be some later impediment to full restoration of fat stores.

Perceived expressed emotion in the siblings and parents of hospitalized patients with anorexia nervosa.

OBJECTIVE: The present study investigated the relationship between the level of perceived Expressed Emotion (EE) of the siblings and parents of patients hospitalized with anorexia nervosa and its effect on weight gain and psychological functioning. METHOD: The Level of Expressed Emotion (LEE) Scale was administered on admission to 19 patients with anorexia nervosa who completed the LEE three times so as to identify their perceptions of their relationship with their closest age sibling, mother, and father. They were also required to complete the Eating Disorder Inventory 2 (EDI-2). Patients' closest age sibling completed the Family Attitude Scale (FAS). The patients' body mass index (BMI) was calculated 6 weeks later, and the EDI-2 readministered. RESULTS: Perceived EE was not predictive of BMI change after 6 weeks of hospitalization. A composite perceived family EE score was a significant predictor of change on the Interpersonal Distrust, Maturity Fears, and Perfectionism subscales of the EDI-2. DISCUSSION: These findings suggest that patients' perceptions of their relationships with their closest aged sibling, mother, and father are poor predictors of weight gain and improvement in psychological functioning following 6 weeks of inpatient treatment.

Fluid restriction in anorexia nervosa: a neglected symptom or new phenomenon?

OBJECTIVE: The deliberate restriction of fluids to control weight is even more dangerous than food restriction since it results in several serious medical complications. However, there has been scant attention given to the anorexia nervosa patient's manipulation of fluids. It is our clinical impression that fluid restriction in this illness is more common than previously thought. METHOD: We summarize the demographic and clinical features of six cases of anorexia nervosa and one case of eating disorder not otherwise specified (ED-NOS) (subthreshold anorexia nervosa), where fluid restriction was a major behavioral problem. We then describe two of the anorexia nervosa cases in more detail. All were treated at a dieting disorders unit affiliated with the University of Sydney. Their preadmission history, psychological and physical status on admission, results of physical investigations, the beginning of the fluid restriction, fluid and food intake throughout treatment, and the resolution of the fluid restriction were assessed. RESULTS: Patterns emerged in the relationship between eating and drinking. In all cases, food restriction was severe prior to the onset of fluid restriction but, notably, fluid intake recommenced prior to food intake. The reasons given by patients for restricting fluid were that it contained calories and that it made them feel full. Most anorexic patients equate feeling full with "feeling fat." Furthermore, they feel fully in control when they restrict fluid as well as food and this produces a strong motivation to maintain the behavior. DISCUSSION: The cases illustrate the insidious nature and serious consequences of fluid restriction and the difficulties managing dieting-disordered patients who undertake it. Careful attention must be given to assessment and clinicians should be aware of fluid restriction as an important aspect of anorexic behavior.

Measuring self-esteem in dieting disordered patients: the validity of the Rosenberg and Coopersmith contrasted.

OBJECTIVE: In order to ascertain the most appropriate measure of self-esteem for dieting disordered patients, this study contrasted the construct and convergent validities of two widely used measures. In addition, dieting disordered subgroups were compared on levels of self-esteem. METHOD: One hundred and seventeen male and female patients diagnosed with anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified completed the Rosenberg Self-Esteem Scale (SES), the Coopersmith Self-Esteem Inventory (SEI), and measures of dieting disorder pathology and depression. RESULTS: No significant differences among the three dieting disorder subgroups were found. In determining convergent validity, regression analyses indicated that the SES was a significant predictor of dieting disorder psychopathology whereas the SEI was not. Of the two self-esteem measures, only the SES showed evidence of convergent validity. DISCUSSION: The results suggest that the SES has sounder construct and convergent validity than the SEI. Hence, the SES may be more appropriate for use with dieting disordered populations.

Bulimia nervosa, restrained, and unrestrained eaters: a comparison of non-binge eating behavior.

OBJECTIVE: This study investigated non-binge eating behavior in bulimia nervosa, restrained and unrestrained eaters. METHOD: Nine females with bulimia nervosa, 12 female restrained eaters, and 13 female unrestrained eaters were administered the Eating Disorder Inventory-2 (EDI-2), the Body Shape Questionnaire, the Beck Depression Inventory, the Rosenberg Self-Esteem Scale, and the Revised Restraint Scale (RRS). All subjects were videotaped during a midday meal and their eating behavior was subsequently rated using the Eating Behaviour Rating Scale (EBRS). RESULTS: EBRS ratings were higher for bulimic than for unrestrained subjects. Restrained subjects' ratings did not differ from those of either bulimic or unrestrained subjects. EBRS scores were positively correlated with RRS and EDI-2 total scores. CONCLUSIONS: Bulimic subjects display aberrant eating behavior, and the extent to which subjects engage in maladaptive eating behavior is related to the degree of eating pathology. These results support the utility of the EBRS as a useful index of eating behaviors in clinical and nonclinical populations.

Is there a relationship between bulimia nervosa and hazardous alcohol use?

OBJECTIVE: The present study investigates the relationship between hazardous alcohol consumption and bulimia nervosa in a clinical population. METHOD: The Alcohol Use Disorders Identification Test (AUDIT) was administered to two groups of female subjects: patients with bulimia nervosa (n = 30) and nonbulimic controls (n = 15). These two groups were further subdivided on the basis of personality disorder as assessed by the Personality Disorder Examination (PDE), a comprehensive interview covering all of the criteria for the 13 DSM-III-R Axis II disorders. The bulimic patients were referred to a dieting disorders clinic affiliated with the University of Sydney. All met DSM-III-R criteria for bulimia nervosa and all had Body Mass Indices (BMIs) greater than 19. The nonbulimic control group were recruited from an undergraduate psychology course. All subjects were given the Bulimic Investigatory Test, Edinburgh (BITE) and the Eating Disorders Inventory-2 (EDI-2). RESULTS: 66.7% (8/12) of personality disordered bulimic patients were drinking at hazardous levels whereas 61.1% (11/18) of bulimic patients without a personality disorder were doing likewise. Furthermore, 35.7% (5/14) of the nonbulimic controls without personality disorders were drinking at hazardous levels and the only control subject with a personality disorder was doing likewise. The association between personality disorder diagnosis and hazardous alcohol use in the bulimic sample just failed to reach significance at the 5% level (chi 2 1,upper .05 = 3.84, p = .052). No association between Axis 1 diagnosis of bulimia nervosa and hazardous alcohol use was found (chi 2 1,upper .05 = 3.84, p = .52). DISCUSSION: The results of the present study suggest we may need to rethink the relationship between hazardous alcohol use and bulimia nervosa reported in the literature, as it may be an artifact of the relationship between personality disorder and hazardous alcohol consumption. Further research is necessary to clarify this issue.

Perceptions of bed rest by anorexic patients.

OBJECTIVE: Few studies have investigated perceptions of operant conditioning programs by anorexic patients. This study examined patients' perceptions of the Bed Rest (BR) component which is employed in some operant conditioning programs. METHODS: A sample of 48 anorexic inpatients was administered a survey to elicit their attitudes towards BR. RESULTS: Results from the survey suggested that most patients perceived BR in a negative way. The main complaint, however, was not punishment or humiliation, as predicted, but isolation and boredom. A number of patients concluded that they wanted more individualization and distraction and less restriction while on BR. DISCUSSION: The findings justify the use of BR within a humane framework in the inpatient treatment of anorexia nervosa, but suggest that patients' perceptions of BR warrant systematic scrutiny.

Attentional biases in eating disorders: a visual probe detection procedure.

OBJECTIVE: To investigate attentional biases for body shape and weight-related stimulus words among subjects with anorexia nervosa, bulimia nervosa, and control subjects classified using a measure of dietary restraint. METHODS: A visual probe detection task was used to assess attention toward stimulus words reflecting either a thin or a large physique and positively or negatively valenced emotion words. RESULTS: In comparison to controls, subjects with eating disorders detected target probes more slowly when they appeared in the same location as had stimulus words connoting a thin physique. In addition, there was a trend toward faster detection or target probes that appeared in the same location as had stimulus words connoting a large physique. Neither of these effects were observed among restrained eaters. DISCUSSION: Our results extend prior work suggesting information-processing biases for body shape and weight-related stimuli among persons with eating disorders.

Conscious and preconscious processing of food, body weight and shape, and emotion-related words in women with anorexia nervosa.

OBJECTIVE: The present study was conducted to extend prior research on attention toward food and body weight and shape-related stimuli in women with eating disorders. METHOD: A modified Stroop color-naming task was completed by women with anorexia nervosa and by control females subdivided on a measure of dietary restraint. Eating disorder-relevant word categories included words connoting fatness, words connoting thinness, low caloric density food words, high caloric density food words, and neutral, control words. Valence effects were controlled for by including positively and negatively valenced emotion words. Stimuli were presented under both unmasked and masked conditions. RESULTS: Using unmasked stimuli, patients with anorexia nervosa, but not unrestrained or restrained eaters, had delayed color-naming latencies for both thin and fat word categories and, to a lesser extent, for high caloric density food words. No differences were observed with masked stimuli. DISCUSSION: Our findings suggest that both thinness and fatness are especially salient to women with anorexia. The lack of effects for emotion words suggests that these findings do not reflect a valence effect. We found no evidence for preconscious attentional biases in the masked condition.

Intensive nutritional counselling in bulimia nervosa: a role for supplementation with fluoxetine?

OBJECTIVE: The aims of the paper are to determine whether nutritional counselling is associated with an improvement in bulimic symptomatology, whether this improvement is maintained during post-treatment follow-up, and whether the addition of fluoxetine 3 x 20 mg/day confers additional benefit. METHOD: Psychological, pharmacological and combined psychopharmacological treatments of bulimia nervosa were reviewed briefly. Sixty-seven patients referred to specialist eating disorder services who fulfilled strict diagnostic criteria were treated with intensive nutritional counselling and randomly assigned to either fluoxetine 3 x 20 mg/day or placebo. After a 1-week 'wash-out', active treatment was given over 8 weeks, followed by post-treatment interviews at 12 and 20 weeks. RESULTS: Both groups of patients improved significantly during treatment. In some respects, the fluoxetine group did slightly better as demonstrated by the items 'restraint', 'weight concern' and 'shape concern' (p < 0.05 vs p < 0.0001) on the Eating Disorder Examination (EDE). Fluoxetine patients decreased their energy intake and lost a modest amount of weight. They went on to regain weight during the follow-up period, returning to levels higher than they were initially. These patients also appeared more likely to have a recurrence of symptoms, as shown by the fall in percentage of binge-free patients and by changes in the EDE. CONCLUSION: Nutritional counselling is an effective means of treating bulimia nervosa, with improvement maintained up to 3 months follow-up. The addition of fluoxetine may confer some benefit during active treatment, but its discontinuation may contribute to a higher rate of recurrence of symptoms post treatment. Of course, this study cannot be extrapolated to the efficacy of fluoxetine when used as the only form of treatment in patients for whom intensive nutritional counselling or other structured psychological programs are not available.

The use of guardianship legislation for anorexia nervosa: a report of 15 cases.

OBJECTIVE: This paper investigates compulsory treatment under guardianship legislation for 15 anorexia nervosa patients admitted to four eating disorders units in New South Wales (NSW), Australia, between 1991 and 1994. METHODS: A retrospective follow-up was conducted. This involved an analysis of sociodemographic, clinical, eating and weight history, and Guardianship Order details obtained from medical records. This small sample was compared to a larger sample of anorexia nervosa patients admitted voluntarily to a specialised eating disorder unit in NSW. Further follow-up included a structured interview using the Morgan-Russell Assessment Outcome Schedule at least 1 year after admission for compulsory treatment. RESULTS: For those treated involuntarily, a larger number came from metropolitan Sydney and a larger percentage were unemployed, were purgers and required specialist medical consultations. A significantly higher proportion came from higher socioeconomic groups, and the duration of stay in hospital while patients were under guardianship was significantly greater. A high degree of comorbidity was noted. There were similarities between those treated involuntarily and those treated voluntarily for the source of referral, marital status and Body Mass Index on admission and discharge. Only three patients accepted a follow-up interview using the Morgan-Russell Outcome Schedule. Two of them had made a good recovery. CONCLUSIONS: It was noted that the guardianship sample comprised a more severely III group than anorexic patients treated voluntarily. The nature of guardianship legislation compared to mental health law was discussed and advice offered to clinicians contemplating and implementing compulsory treatment.

Chronic fatigue syndrome and dieting disorders: diagnosis and management problems.

OBJECTIVE: This paper illustrates the importance of conducting an initial and ongoing psychiatric assessment of patients with chronic fatigue syndrome in order to diagnose dieting disorders. The diagnostic issues and management problems of three case vignettes, two with anorexia nervosa and one with bulimia nervosa, are described. METHOD: The treatment response of dieting disordered patients is generally prolonged after a previous diagnosis of chronic fatigue syndrome has been made and the patient and family favour a disease diagnosis. RESULTS: Several management problems arise and family members may also be reluctant to accept a dieting disorder diagnosis. CONCLUSIONS: Early detection of dieting disorders by adequate screening and assessment is necessary so that a significant reduction in morbidity may occur.