Childhood eating and weight in eating disorders: a multi-centre European study of affected women and their unaffected sisters.

BACKGROUND: Previous studies have suggested that childhood eating and weight problems may be risk factors for eating disorders. Robust evidence is still lacking. AIMS: To investigate whether childhood eating and weight problems increase the risk of eating disorders in affected women compared to their unaffected sisters. METHODS: Women (150) with anorexia (AN) or bulimia nervosa (BN) recruited from clinical and community samples were compared to their unaffected sister closest in age on maternal reports of childhood eating and weight. RESULTS: Women with BN were significantly more overweight at the ages of 5 and 10 (both OR = 2.8, p < 0.01), ate a lot (OR = 1.3, p < 0.01), were less picky (OR = 0.6, p < 0.05) and ate quickly (OR = 2.3, p < 0.05) between the ages of 6 and 10 compared to their healthy sisters. Significantly more women with AN were described as having a higher weight at 6 months (OR = 0.8, p < 0.01) and 1 year (OR = 0.6, p < 0.01) compared to their healthy sisters. Childhood eating was comparable in the women with AN and their unaffected sisters. CONCLUSIONS: Traits of childhood overeating were more common in bulimic women compared to their unaffected siblings. Subjects with AN did not differ from their sisters on eating variables. The increased risk of BN due to childhood overweight suggests that prevention strategies for childhood obesity and overweight may therefore be applicable in BN.

Establishing a useful distinction between current and anticipated bodily shame in eating disorders.

Previous research has suggested a role for bodily shame in the development of bulimia. The purpose of the present study was to extend this research by exploring a temporal perspective on bodily shame and eating pathology. Specifically, we were interested in whether bodily shame associated with the possibility of future weight gain was important in determining eating disorder symptoms independently of any association with bodily shame associated with current body size. A brief questionnaire designed to measure bodily shame was developed for the purposes of this study and administered to four samples (total n=428) of eating disordered and non-eating disordered women who also completed a number of measures of eating pathology. Factor analysis of the bodily shame scale identified three sub-scales, two measuring feelings of bodily shame (one measuring shame associated with current body size and one measuring shame that is anticipated should the individual gain weight) and a third measuring the perceived unattractiveness of being overweight. Anticipated bodily shame made a significant additional contribution to predicting eating disorder symptoms over and above that made by current bodily shame. A focus on feelings of bodily shame as they are currently experienced may limit the usefulness of this construct in eating disorder research. Since shame can be both punishing and prohibitive, consideration of the anticipation of shame as a consequence of weight gain may be a useful addition to understanding eating disordered behaviours, particularly in relation to symptoms concerning the prevention of weight gain rather than just the achievement of weight loss.

Specificity in the relationship between depressive and eating disorder symptoms in remitted and nonremitted women.

OBJECTIVE: There is a strong association between eating disorders and depression. However, because both eating disorder symptoms and depression are multifactorial, this study explored the relationship between these two disorders in women with eating disorders and women in remission. METHOD: Two hundred and eight (mostly female) volunteers with a history of eating disorders participated. They completed a self-report questionnaire of eating disorder symptoms, the Short Evaluation for Eating Disorders (SEED), and a questionnaire measuring depression, the Beck Depression Inventory (BDI). RESULTS: According to the SEED, 57 volunteers were classified as being in remission and 151 were classified as being ill. Those who were in remission were significantly less depressed overall than those who were still ill with 72% of the former falling in the "not depressed" or "mildly depressed" categories and 73% of the latter falling in the "moderately" or "severely depressed" categories. Factor analyses of the SEED and BDI identified three subscales of eating disorder symptoms (dietary restriction, bulimia, and body mass index [BMI]/menstruation) and two subscales of depression (cognitive and somatic/affective). Dietary restriction and bulimia, but not BMI/menstruation, were uniquely associated with the cognitive symptoms of depression. However, none of the eating disorder symptoms were uniquely associated with the somatic/affective symptoms of depression. DISCUSSION: Although eating disorders and depression share considerable comorbidity, a specific association is restricted to that between the cognitive and behavioral symptoms of eating disorders and the cognitive symptoms of depression.

Evidence for long-term pancreatic damage caused by laxative abuse in subjects recovered from anorexia nervosa.

OBJECTIVE: This study examined whether a prior history of laxative abuse results in long-term changes in gastrointestinal function. METHOD: The functioning of the enteroinsular axis was examined by measuring the insulin response to a standard meal. The study involved 18 subjects who had fully recovered from anorexia nervosa (AN) and an age and weight-matched control group. In the recovered group, 10 of 18 subjects had a history of laxative abuse. RESULTS: Subjects with a prior history of laxative abuse show a more gradual increase and decrease in insulin secretion, but no differences in glucose response or hunger ratings. DISCUSSION: Because there are no differences in the glucose response to the meal, it is hypothesized that the difference in insulin response is due to changes in the enteroinsular axis. These data indicate that chronic laxative abuse induces long-term changes in gastrointestinal function.

Individual-specific risk factors for anorexia nervosa: a pilot study using a discordant sister-pair design.

BACKGROUND: The aim of this pilot study was to examine which unique factors (genetic and environmental) increase the risk for developing anorexia nervosa by using a case-control design of discordant sister pairs. METHODS: Forty-five sister-pairs, one of whom had anorexia nervosa and the other did not, were recruited. Both sisters completed the Oxford Risk Factor Interview for Eating Disorders and measures for eating disorder traits, and sib-pair differences. Blood or cheek cell samples were taken for genetic analysis. Statistical power of the genetic analysis of discordant same-sex siblings was calculated using a specially written program, DISCORD. RESULTS: The sisters with anorexia nervosa differed from their healthy sisters in terms of personal vulnerability traits and exposure to high parental expectations and sexual abuse. Factors within the dieting risk domain did not differ. However, there was evidence of poor feeding in childhood. No difference in the distribution of genotypes or alleles of the DRD4, COMT, the 5HT2A and 5HT2C receptor genes was detected. These results are preliminary because our calculations indicate that there is insufficient power to detect the expected effect on risk with this sample size. CONCLUSIONS: A combination of intrinsic and extrinsic factors increases the risk of developing anorexia nervosa. It would, therefore, be informative to undertake a larger study to examine in more detail the unique genetic and environmental factors that are associated with various forms of eating disorders.

Differential environmental factors in anorexia nervosa: a sibling pair study.

OBJECTIVES: Previous studies have explored differences in psychosocial and familial factors between women who develop anorexia nervosa and those who do not. However, these studies have generally used between-group comparisons. This study looks at the environmental factors which may be antecedents of anorexia nervosa looking at sister pairs where one had anorexia nervosa and the other did not. DESIGN: A paired design was used to compare anorexic women with an unaffected sister on a number of background variables, including sibling interaction, parental care, peer group characteristics and other events unique to the individual. METHODS: The Sibling Inventory of Differential Experience (SIDE) was used to determine non-shared environment. Out of an initial sample of 148 women with past or current anorexia nervosa, 28 were identified who had sisters with no reported history of eating disorders and who also consented to complete the questionnaire. RESULTS: Anorexic sisters perceived more maternal control and reported more antagonism towards and jealousy of their sisters than did unaffected sisters. In addition, anorexic women reported having had fewer friends and boyfriends than their sisters. CONCLUSIONS: These results confirm the perceived differences in background environment between women with and women without anorexia nervosa. These issues are discussed in relation to behavioural genetics, family dynamics and psychosexual development.

Disgust sensitivity in eating disorders: a preliminary investigation.

BACKGROUND: Disgust is a basic emotion that has been relatively neglected in psychiatry in general and in eating disorders in particular. Nevertheless, there are features of disgust and its more complex derivatives (e.g., shame) which suggest that disgust may have a role to play in eating disorders. METHOD: Seventy-four patients with a DSM-IV diagnosis of anorexia nervosa, bulimia nervosa, eating disorder not otherwise specified, and obese binge eater were compared with 15 control subjects on their levels of disgust sensitivity. RESULTS: Overall, eating disorder patients did not appear to be more sensitive to disgust-eliciting stimuli than comparison subjects, although there was a tendency for patients to be more disgusted by body products. However, drive for thinness and bulimia scores were related to higher levels of disgust sensitivity to food, death, and magical contagion. General psychopathology did not appear to be related to levels of disgust sensitivity. DISCUSSION: Although patients are not more sensitive than controls to the disgust-eliciting stimuli measured, disgust still has a positive relationship to eating disorder symptoms. Future studies will need to examine more precisely what this relationship might be.

Engagement and outcome in the treatment of bulimia nervosa: first phase of a sequential design comparing motivation enhancement therapy and cognitive behavioural therapy.

Despite the major advances in the development of treatments for bulimia nervosa, drop-outs and a lack of engagement in treatment, continue to be problems. Recent studies suggest that the transtheoretical model of change may be applicable to bulimia nervosa. The aim of this study was to examine the roles of readiness to change and therapeutic alliance in determining engagement and outcome in the first phase of treatment. One hundred and twenty five consecutive female patients meeting DSM-IV criteria for bulimia nervosa took part in a randomised controlled treatment trial. The first phase of the sequential treatment compared four sessions of either cognitive behavioural therapy (CBT) or motivational enhancement therapy (MET) in engaging patients in treatment and reducing symptoms. Patients in the action stage showed greater improvement in symptoms of binge eating than did patients in the contemplation stage. Higher pretreatment scores on action were also related to the development of a better therapeutic alliance (as perceived by patients) after four weeks. However, pretreatment stage of change did not predict who dropped out of treatment. There were no differences between MET and CBT in terms of reducing bulimic symptoms or in terms of developing a therapeutic alliance or increasing readiness to change. The results suggest that the transtheoretical model of change may have some validity in the treatment of bulimia nervosa although current measures of readiness to change may require modification. Overall, readiness to change is more strongly related to improvement and the development of a therapeutic alliance than the specific type of treatment.

Events and the onset of eating disorders: correcting an "age old" myth.

BACKGROUND: Previous reports have suggested differences between early and late onset cases both in anorexia nervosa and bulimia nervosa. In anorexia nervosa, women with late onset are thought to be more likely to develop symptoms in response to life events than early onset cases. Women developing anorexia in response to life events are also considered to show different background features. In bulimia nervosa, it is not known whether rates of life events before onset differ in bulimics who develop their disorder at different stages in life. METHOD: Previously published data were reanalyzed to examine differences between women whose eating disorder did or did not develop in response to stress. Seventy-two women with anorexia nervosa (48 with a severe provoking agent) and 29 women with bulimia nervosa (22 with a severe provoking agent) were administered semistructured interviews to assess life events and difficulties in the year before onset, childhood adversity, and other clinical features. RESULTS: In both anorexia nervosa and bulimia nervosa, subjects with or without a severe provoking agent did not differ from each other on age or childhood variables. The only significant difference found was that, in women developing anorexia nervosa, those who later developed bulimic symptoms alongside their anorexia reported a lower rate of provoking agents (31%) than those anorexic women who either maintained their restriction (76%) or went on to develop normal weight bulimia nervosa (69%). CONCLUSION: There are no differences between women whose eating disorder develops in response to stress and those who do not. Women presenting for treatment with anorexia nervosa of the binge-purge subtype are unlikely to have developed their illness in response to a severe provoking agent.

Stress, coping, and crisis support in eating disorders.

OBJECTIVE: Recent research has supported the role of stress in the development and maintenance of eating disorders. However, coping and crisis support, important aspects of this stress process, have received little systematic attention. The cognitive-transactional approach to coping emphasizes the importance of the relationship between the individual and the particular problematic situation and yet most studies investigating coping in eating disorders have failed to measure situation-specific coping. METHOD: The present study used semistructured interviews to measure coping and crisis support in response to severe events and/or marked difficulties in 12 women with anorexia nervosa (AN), 21 women with bulimia nervosa (BN), and 21 women without an eating disorder (non-ED). RESULTS: Women with eating disorders were more likely to use cognitive avoidance or cognitive rumination and were less likely to downplay their problems. In addition, BN subjects were more likely to blame themselves and were less likely to receive crisis support from a core-tie. Overall, women with eating disorders were less likely to be masterful in response to crises than women without eating disorders. DISCUSSION: It is concluded that women with eating disorders are less effective in their coping than women without eating disorders.

Setting the scene for eating disorders, II. Childhood helplessness and mastery.

BACKGROUND: Previous studies have examined childhood factors that appear to increase the risk of developing an eating disorder (e.g. sexual abuse and parental care). Studies have not yet examined whether the way in which women cope with these adversities in childhood influences the risk. METHOD: Using a semi-structured interview, childhood helplessness and mastery were measured (based on behavioural indices) in women with and without a history of eating disorders. RESULTS: There was a higher rate of childhood helplessness and a lower rate of childhood mastery in women with eating disorders compared to those without. Furthermore, this difference did not appear to be a result of current psychiatric state. CONCLUSION: It is concluded that it is not simply the presence of adversity in childhood which is of aetiological importance in the development of eating disorders but the way in which these are negotiated.

Intriguing links between animal behavior and anorexia nervosa.

OBJECTIVE: The aim of this review is to examine the literature on possible animal models for anorexia nervosa. METHOD: The literature was searched using MedLine, PSYCHLIT, and CAB Abstracts using search items that included body composition, thin sow syndrome, and halothane gene. In addition, key workers in the field of animal husbandry and body composition were sent earlier drafts of the paper for comment. RESULTS: Thin sow syndrome in pigs has some similarities to anorexia nervosa. Leanness and susceptibility to stress are associated in pigs with mutations of the ryanodine gene. Body composition in animals has a high heritability and various components of this overall composite trait are influenced to a major extent by polymorphism at specific gene loci. DISCUSSION: Recent developments in understanding body composition in animals offer intriguing insights into anorexia nervosa and suggest several candidate genes which would be worthy of further examination.

Predictors of outcome for two treatments for bulimia nervosa: short and long-term.

OBJECTIVE: This study examined pretreatment variables to predict outcome in two treatments for bulimia nervosa. METHOD: Patients were offered either 16 weeks of cognitive-behavioral therapy (CBT) or a self-treatment manual followed by up to 8 weeks of CBT (sequential group). Using complete data, stepwise regression analyses were performed. RESULTS: It was found that a longer duration of illness and lower binge frequency predicted a better outcome both at the end of treatment (p < .001) and at 18 months of follow-up (p < .005). In the sequential group, lower pretreatment binge frequency predicted better outcome at the end of treatment (p < .05) and at 18 months of follow-up (p < .05). In the CBT group, longer duration of illness predicted better outcome at the end of treatment (p < .02). DISCUSSION: It is concluded that (1) those with more frequent binging may require a more intense intervention and (2) those who have been ill longer may be more motivated to respond to treatment.

Social support in patients with anorexia nervosa and bulimia nervosa.

OBJECTIVE: To investigate the social support networks of patients with anorexia nervosa (AN) and bulimia nervosa (BN). METHOD: Social support was measured using the Significant Others Scale for 44 patients with AN, 81 patients with BN, and 86 polytechnic students. RESULTS: Eating disorder patients had smaller social networks than the students. AN patients were significantly less likely than BN patients to have a spouse or partner as a support figure. Both AN and BN patients reported less actual emotional and practical support than students. AN patients perceived their social support to be adequate, whereas BN patients were dissatisfied with their support. Patients set lower ideals for support than the students. Social support was not correlated with duration of illness. DISCUSSION: AN and BN patients have deficient social networks. In BN patients there is disturbance in both the size and perceived adequacy of social relationships.

Psychosocial factors in the onset of eating disorders: responses to life-events and difficulties.

A number of studies have proposed a role for stress in the onset of eating disorders. Initially the focus was on the life-events and difficulties themselves. However, the aim of this study was to examine the coping and support elicited in response to the crises that precipitate onset of eating disorders. Thirty-two women who had developed an eating disorder within four years of presentation were administered semi-structured interviews asking about events and difficulties in the year before onset, as well as how they coped and the support they received. Twenty women with no history of eating disorders acted as a comparison group. Results show that the onset of anorexic symptoms is associated with cognitive avoidance in response to a crisis while the onset of bulimic symptoms is associated with cognitive rumination. In addition, women who developed an eating disorder were more likely to be helpless in response to the crisis than women who did not develop an eating disorder. It is concluded that coping interventions may be useful in terms of primary and relapse prevention.

Feelings and fantasy in eating disorders: a factor analysis of the Toronto Alexithymia Scale.

The aim of the study was to examine the factor structure of alexithymia in patients with eating disorders and to compare scores on these factors with a non-eating disordered population. The Toronto Alexithymia Scale (TAS) was given to patients with restricting anorexia nervosa (AN/R, n = 29), bulimia nervosa (BN, n = 83), anorexia with a subtype bulimia (AN/BN, n = 15), and 79 female students. Factors were extracted using a principal-components factor analysis. Four factors were found--inability to Identify Feelings, Paucity of Fantasy, Noncommunication of Feelings, and Concrete Thinking. All three eating disorder groups were less able to identify their feelings than the comparison group and AN/R patients had a more diminished fantasy life than BN patients and students. Groups did not differ significantly on concrete thinking but there was a trend towards significance on noncommunication of feelings, with patient groups expressing their feelings less than comparison subjects. Differences between patient groups on factors of the TAS suggest that scores are not simply a result of psychopathology in general. Approaches which promote the identification and expression of feelings may be particularly useful in the treatment of eating disorders.

[Help with self-care]. / Hilfen zur Selbstbehandlung.

Instructions for self-treatment, whether printed, presented via computer or by audiovisual means, are effective in the management of phobias, panic disorder, other anxieties, depression, bulimia nervosa, obesity, alcohol problems, nicotine abuse, myocardial infarction, AIDS, compliance problems and the counseling of patients' relatives. A lasting improvement has been shown for up to 7 years. The mechanisms of effective self-change are discussed.