The clinical utility of personality subtypes in patients with anorexia nervosa.

OBJECTIVE: Elucidation of clinically relevant subtypes has been proposed as a means of advancing treatment research, but classifying anorexia nervosa (AN) patients into restricting and binge-eating/purging types has demonstrated limited predictive validity. This study aimed to evaluate whether an approach to classifying eating disorder patients on the basis of comorbid personality psychopathology has utility in predicting treatment response and readmission in patients with AN. METHOD: Data were collected from 154 AN patients (M [SD] age = 25.6[9.4] years; 95.5% female; 96.8% Caucasian) at admission, discharge, and 3 months postdischarge from intensive treatment. Latent profile analysis of personality traits assessed at admission was performed to classify participants into personality subtypes, which were then used to predict outcomes at discharge and risk of readmission. RESULTS: The best fitting model identified 3 personality subtypes (undercontrolled, overcontrolled, low psychopathology) that contributed significantly to multivariate models predicting study outcomes. Undercontrolled patients were more likely to have a poor outcome at discharge than overcontrolled (OR = 3.56, p = .01) and low psychopathology patients (OR = 11.23, p < .001). Undercontrolled patients also had a greater risk of discharge against medical advice (HR = 2.08, p = .02) and readmission than overcontrolled patients (HR = 3.76, p = .009). Binge-eating/purging versus restricting subtypes did not predict discharge against medical advice or readmission in the multivariate models. CONCLUSIONS: Findings support the clinical utility of personality subtypes in AN. Future work is needed to identify mechanisms that explain diminished treatment response in undercontrolled patients and to develop interventions for this high-risk group.

Emotion avoidance in patients with anorexia nervosa: initial test of a functional model.

OBJECTIVE: This study aimed to evaluate emotion avoidance in patients with anorexia nervosa (AN) and to examine whether emotion avoidance helps to explain (i.e., mediates) the relation between depressive and anxiety symptoms and eating disorder (ED) psychopathology in this group. METHOD: Seventy-five patients with AN completed questionnaires to assess study variables. Rates of emotion avoidance were compared to published data, and regression models were used to test the hypothesis that emotion avoidance mediates the relation between depressive and anxiety symptoms and ED psychopathology in AN. RESULTS: Patients with AN endorsed levels of emotion avoidance that were comparable to or higher than other psychiatric populations and exceeded community controls. As predicted, emotion avoidance significantly explained the relations of depressive and anxiety symptoms to ED psychopathology. DISCUSSION: Findings confirm that emotion avoidance is present in patients with AN and provide initial support for the idea that anorexic symptoms function, in part, to help individuals avoid aversive emotional states.

Family-based treatment of severe pediatric obesity: randomized, controlled trial.

OBJECTIVE: We evaluated the efficacy of family-based, behavioral weight control in the management of severe pediatric obesity. METHODS: Participants were 192 children 8.0 to 12.0 years of age (mean +/- SD: 10.2 +/- 1.2 years). The average BMI percentile for age and gender was 99.18 (SD: 0.72). Families were assigned randomly to the intervention or usual care. Assessments were conducted at baseline, 6 months, 12 months, and 18 months. The primary outcome was percent overweight (percent over the median BMI for age and gender). Changes in blood pressure, body composition, waist circumference, and health-related quality of life also were evaluated. Finally, we examined factors associated with changes in child percent overweight, particularly session attendance. RESULTS: Intervention was associated with significant decreases in child percent overweight, relative to usual care, at 6 months. Intent-to-treat analyses documented that intervention was associated with a 7.58% decrease in child percent overweight at 6 months, compared with a 0.66% decrease with usual care, but differences were not significant at 12 or 18 months. Small significant improvements in medical outcomes were observed at 6 and 12 months. Children who attended > or =75% of intervention sessions maintained decreases in percent overweight through 18 months. Lower baseline percent overweight, better attendance, higher income, and greater parent BMI reduction were associated with significantly greater reductions in child percent overweight at 6 months among intervention participants. CONCLUSIONS: Intervention was associated with significant short-term reductions in obesity and improvements in medical parameters and conferred longer-term weight change benefits for children who attended > or =75% of sessions.

Temperament, mood, dietary restraint, and bulimic symptomatology in college women.

The current study examined whether biologically-influenced temperamental traits implicated in the pathogenesis of disordered eating behaviors contribute to their development over and above current negative affect and dietary restraint. Participants (N=276) were undergraduate psychology women who completed the BULIT-R, BDI-II, STAIS, RS, and the MPQ. Temperamental characteristics, particularly increased Negative Emotionality and decreased Positive Emotionality, were significantly associated with increased levels of bulimic symptomatology. Moreover, these dimensions accounted for small, but statistically significant amounts of the variance of bulimic symptomatology over and above current negative affect and dietary restraint. Contrary to expectations, impulsivity did not predict bulimic symptoms. This study provides evidence that temperamental dimensions related to mood rather than impulsivity are associated with bulimic symptomatology and contribute to bulimic symptoms over and above state mood and dietary restraint. Future empirical studies are needed to clarify relationships between temperament and other risk factors for disordered eating.

Subtyping children and adolescents with loss of control eating by negative affect and dietary restraint.

OBJECTIVE: Research suggests that subtyping adults with binge eating disorders by dietary restraint and negative affect predicts comorbid psychopathology, binge eating severity, and treatment outcome. Little research has explored the validity and clinical utility of subtyping youth along these dimensions. METHOD: Children (aged 8-18 years) reporting loss of control eating (n=159) were characterized based upon measures of dietary restraint and negative affect using cluster analysis, and then compared regarding disordered eating attitudes and behaviors, and parent-reported behavior problems. RESULTS: Robust subtypes characterized by dietary restraint (n=114; 71.7%) and dietary restraint/high negative affect (n=45; 28.3%) emerged. Compared to the former group, the dietary restraint/high negative affect subtype evidenced increased shape and weight concerns, more frequent binge eating episodes, and higher rates of parent-reported problems (all ps<0.05). CONCLUSION: Similar to findings from the adult literature, the presence of negative affect may mark a more severe variant of loss of control eating in youth. Future research should explore the impact of dietary restraint/negative affect subtypes on psychiatric functioning, body weight, and treatment outcome.

A family history study of binge-eating disorder.

Family studies of anorexia nervosa and bulimia nervosa have yielded important information about the etiologies of these eating disorders. By contrast, little is known about familial factors of etiologic importance for binge-eating disorder (BED). The purpose of the current family history study was to assess the prevalence of comorbid psychopathology in a non-treatment seeking female sample of 31 probands with BED, 32 control probands without BED, and their 283 first-degree relatives. In-person semistructured clinical interviews were conducted with the probands, who also served as informants for all of their first-degree relatives. Significantly higher lifetime rates of major depressive disorder, dysthymic disorder, and social phobia were found among women with BED compared with control women. Significantly higher lifetime rates of bipolar (I or II) disorder, any depressive disorder, nearly all anxiety disorders, anorexia nervosa, and BED were reported among the first-degree relatives of women with BED compared with the first-degree relatives of control women. Furthermore, female relatives of women with BED were reported to have higher rates of substance use disorders and dysthymic disorder compared with female relatives of control women without BED. Nearly all disorders that were elevated in relatives of women with BED followed a pattern of independent transmission from BED. The primary exception was substance use disorder among female relatives, whose transmission pattern was consistent with that of a shared etiology with BED. Thus, BED and substance use disorder may share a common mechanism of familial transmission among women.

A multisite investigation of binge eating behaviors in children and adolescents.

The phenomenology of childhood and adolescent loss of control (LOC) eating is unknown. The authors interviewed 445 youths to assess aspects of aberrant eating. LOC was associated with eating forbidden food before the episode; eating when not hungry; eating alone; and experiencing secrecy, negative emotions, and a sense of "numbing" while eating (ps<.01). Hierarchical cluster analysis revealed a subgroup, most of whom reported LOC eating. Cluster members reported having a trigger initiate episodes, eating while watching television, and having decreased awareness regarding the amount consumed. The authors conclude that aspects of LOC eating during youth are similar to aspects of adult episodes, but a youth-specific presentation may exist. Findings may provide an intervening point to prevent excessive weight gain and eating disorders.

Depressive and manic-hypomanic spectrum psychopathology in patients with anorexia nervosa.

OBJECTIVE: We used a dimensional measure of mood psychopathology to document lifetime depressive and manic-hypomanic spectrum symptoms in 50 patients with anorexia nervosa (AN). METHOD: Participants provided demographic information and completed the Self-Report Questionnaire for Mood Spectrum, a 161-item instrument that documents lifetime symptoms, traits, and behaviors characteristic of threshold and subthreshold mood episodes. Analyses focused on the association of depressive and manic-hypomanic component scores with indicators of clinical severity in AN. RESULTS: Lifetime severity of depressive (M[SD] = 39.1[13.9]) and manic-hypomanic (M[SD] = 23.8[12.1]) spectrum symptoms exceeded the established thresholds for clinical significance on these scales (ie, score > or =22). There was a positive correlation between the number of manic-hypomanic items endorsed and the number of depressive items endorsed. After controlling for lifetime history of mood disorder, severity of depressive and manic-hypomanic spectrum symptomatology also was associated with a history of self-induced vomiting and suicidality in patients with AN. CONCLUSION: These data provide initial evidence for the clinical significance of depressive and manic-hypomanic spectrum symptoms in patients with AN. Future work is needed to determine how mood spectrum psychopathology might impact the course and treatment of AN.

Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status.

OBJECTIVE: The present study was designed to document psychiatric disorders among candidates for weight loss surgery and to examine the relationship of psychopathology to degree of obesity and functional health status. METHOD: The authors collected demographic and clinical information from 288 individuals seeking surgery. Assessments were administered independently of the preoperative screening and approval process. The study group was mostly female (83.3%) and white (88.2%). Mean body mass index (BMI) of the group was 52.2 kg/m(2) (SD=9.7), and the mean age was 46.2 years (SD=9.4). RESULTS: Approximately 66% of the participants had a lifetime history of at least one axis I disorder, and 38% met diagnostic criteria at the time of preoperative evaluation. In addition, 29% met criteria for one or more axis II disorders. Axis I psychopathology, but not axis II, was positively related to BMI, and both axis I and axis II psychopathology were associated with lower scores on the Medical Outcomes Study 36-item Short-Form Health Survey. CONCLUSIONS: Current and past DSM-IV psychiatric disorders are prevalent among bariatric surgery candidates and are associated with greater obesity and lower functional health status, highlighting the need to understand potential implications for surgery preparation and outcome. Future work also will focus on the course of psychiatric disorder during the post-surgery period and its relationship to weight loss and maintenance.

Eating disorder symptomatology among ballet dancers.

OBJECTIVE: The current study sought to compare eating disorder symptomatology among ballet dancers and individuals with restricting anorexia nervosa (RAN), bulimia nervosa (BN), and no eating pathology. METHOD: Twenty-nine female ballet dancers completed assessments and were compared with an archival dataset of 26 women with RAN, 47 women with BN, and 44 women with no eating pathology. Eating disorder diagnoses and behaviors were assessed with a semi-structured clinical interview, the Eating Disorder Inventory (EDI), and a weight history interview. RESULTS: Eighty-three percent of dancers met lifetime criteria for AN (6.9%), BN (10.3%), AN+BN (10.3%), or EDNOS (55.0%). Moreover, dancers looked more similar to eating-disordered individuals than to control individuals on measures of eating pathology. CONCLUSION: Despite previous emphasis on the pathology AN, the current findings suggest that dancers frequently engage in binge eating and purging behaviors. Moreover, it appears that their pathology is as severe as that of non-dancing women with eating disorders.

Overeating among seriously overweight children seeking treatment: results of the children's eating disorder examination.

OBJECTIVE: We sought to examine rates of eating disorder symptoms among seriously overweight children seeking treatment using the Eating Disorder Examination for Children (ChEDE) and to provide initial data about their association with treatment outcome. METHOD: Overweight children (N = 27) 8-13 years old were interviewed using the ChEDE before participating in a family-based behavioral treatment program. Height and weight were measured pretreatment, posttreatment, and approximately 8 months posttreatment. RESULTS: Fifteen percent of children reported subjective bulimic episodes (SBE). Weight loss did not differ for children with and without SBEs, but concerns about body shape were related to larger weight losses during treatment. CONCLUSION: A considerable minority of treatment-seeking overweight children report an episodic sense of loss of control over eating. Loss of control is related to other disordered eating attitudes and behaviors, but does not appear to affect treatment outcome. Future studies are needed to replicate these initial findings.

Recovery of ovarian activity in women with functional hypothalamic amenorrhea who were treated with cognitive behavior therapy.

OBJECTIVE: To determine whether cognitive behavior therapy (CBT) targeted to problematic attitudes common among women with functional hypothalamic amenorrhea would restore ovarian function. DESIGN: Randomized, prospective, controlled intervention. SETTING: Clinical research center in an academic medical institution. PATIENT(S): Sixteen women participated who had functional hypothalamic amenorrhea; were of normal body weight; and did not report psychiatric conditions, eating disorders, or excessive exercise. INTERVENTION(S): Subjects were randomized to CBT or observation for 20 weeks. MAIN OUTCOME MEASURE(S): Serum levels of E(2) and P and vaginal bleeding were monitored. RESULT(S): Of eight women treated with CBT, six resumed ovulating, one had partial recovery of ovarian function without evidence of ovulation, and one did not display return of ovarian function. Of those randomized to observation, one resumed ovulating, one had partial return of ovarian function, and six did not recover. Thus, CBT resulted in a higher rate of ovarian activity (87.5%) than did observation (25.0%), chi(2) = 7.14. CONCLUSION(S): A cognitive behavioral intervention designed to minimize problematic attitudes linked to hypothalamic allostasis was more likely to result in resumption of ovarian activity than observation. The prompt ovarian response to CBT suggests that a tailored behavioral intervention offers an efficacious treatment option that also avoids the pitfalls of pharmacological modalities.