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Background: In this study, we investigate the affective temperamental characteristics in a sample of ED (eating disorder) patients., Methods: 49 ED patients diagnosed by the SCID (Structured Clinical Interview for DSM-IV), were divided into two groups on the basis of the presence or absence of Binge Eating (restricting-anorexia nervosa [R-AN]= 16; Binge Eaters= 33). All patients were administered the TEMPS-I (Temperament Evaluation Memphis Pisa Semistructured - Interview), to assess affective temperament. A third group of controls (N= 1010), derived from a study with the TEMPS-I on normal subjects, was included for comparison., Results: A full affective temperament was not found in patients of the restricting group. By contrast 24% of the binge eating group had a full affective temperament of one of three types. Comparing the three temperaments for the three groups, only cyclothymic temperament proved to be significant, with higher levels in the binge eating group (p<0.01)., Conclusions: In this study, people with R-AN do not show a full affective temperament. However, people with binge eating, had depressive and hyperthymic temperament, and displayed higher level of cyclothymic temperament than the normal population. The findings of this study add to a growing literature on temperament in people with ED; particularly, they add to the view that may be various paths leading to R-AN, and these may differ from those of binge eating.

Objective: The authors compared 62 men who met all or most of the DSM-III-R criteria for eating disorders with 212 women who had similar eating disorders and 3,769 men who had no eating disorders on a wide variety of clinical and historical variables., Method: The groups of subjects were derived from a community epidemiologic survey performed in the province of Ontario that used the World Health Organization's Composite International Diagnostic Interview., Results: Men with eating disorders were very similar to women with eating disorders on most variables. Men with eating disorders showed higher rates of psychiatric comorbidity and more psychosocial morbidity than men without eating disorders., Conclusions: These results confirm the clinical similarities between men with eating disorders and women with eating disorders. They also reveal that both groups suffer similar psychosocial morbidity. Men with eating disorders show a wide range of differences from men without eating disorders; the extent to which these differences are effects of the illness or possible risk factors for the occurrence of these illnesses in men is not clear.

This manuscript reviews the literature involved with the Eating Attitudes Test (EAT), first developed in the late 1970s as a self-report, indicative of the symptoms of eating disorders. The EAT has good psychometric properties of reliability and validity, and reasonable sensitivity and specificity for the eating disorders, but very low positive predictive value because eating disorders are relatively uncommon. In addition they exist on a continuum, because of denial and social desirability, the results of a self-report instrument may be affected. A very large literature has documented the use of the EAT in a variety of cultures. It is used to screen eating disturbances in general as the first part of a two-part diagnostic screen, as an ability to compare across groups and to measure change between groups and over time.

Objective: Patients with eating disorders (EDs) are often difficult to treat. Despite recent advances in treatment, a significant percentage of patients remain treatment refractory. This paper reviews variables that contribute to these difficulties and recent strategies that focus on increasing patient motivation for treatment., Method: The authors relate their clinical experience and synthesize the literature examining aspects of patients with EDs that may contribute to their treatment resistance and therapist variables that may contribute to negative nontherapeutic reactions., Results: Patient variables include the nature of the symptoms that patients experience, issues of trust, the not uncommon failure of ambulatory treatments, and issues related to comorbidity. Aspects of clinicians include lack of understanding of the biopsychosocial pathophysiology of these conditions and lack of experience and appreciation for the countertransferential reactions that these patients evoke in caregivers., Conclusions: Improving understanding of the reasons for treatment refractoriness in patients with EDs is critical to improving their care. New interventions aimed at enhancing motivation may facilitate this process.

Objective: The present study examined changes in women's mood states resulting from their viewing pictures in fashion magazines of models who represent a thin ideal., Method: Female university students completed the Profile of Mood States (POMS), the Body Parts Satisfaction Scale (BPSS), and the Eating Disorder Inventory (EDI). They were then exposed to 20 slides; the experimental group (N = 51) viewed images of female fashion models and a control group (N = 67) viewed slides containing no human figures. All subjects then completed the POMS and the BPSS again., Results: Women were more depressed (R2 = 0.745, p < .05) and more angry (R2 = 0.73, p < .01) following exposure to slides of female fashion models., Discussion: Viewing images of female fashion models had an immediate negative effect on women's mood. This study, therefore, supports the hypothesis that media images do play a role in disordered eating.

This study examines the prevalence of anorexia nervosa and bulimia nervosa in relatives of probands, and examines the probandwise specificity of any familial clustering. Data were collected from probands using the family history method. Probands were recruited in a sequential cohort fashion. Information collected from probands was rated semiblindly by two of the authors, and a diagnostic hierarchy applied to arrive at a diagnosis for each of the relatives assessed. Data are reported on 2,125 family members, collected from 93 probands. Diagnostic agreement between raters was high, with serious disagreement present in three of 167 possible cases of an eating disorder. Rates of anorexia nervosa, bulimia nervosa, major depression, and substance abuse declined from first- to third-degree relatives, which is consistent with genetic clustering, and there was evidence of a cohort effect operating for anorexia nervosa and bulimia nervosa. The rates of anorexia nervosa and bulimia nervosa in all family members were 5.1%, and 4.3% respectively. An analysis of maternal and paternal descent showed no evidence for X-linked dominant transmission in these families. Preliminary analysis of the clustering of diagnoses in relatives showed a tendency (chi 2 = 14.47, P = .006) for family members to be affected by the same diagnosis as was the proband. This trend was strongest for anorexia nervosa, but there was overlap when the proband had a lifetime diagnosis of bulimia nervosa, with or without anorexia nervosa. These results are compatible with the existence of genetic factors influencing predisposition to eating disorders, but do not prove such.

The past thirty years have seen dramatic changes in our approach to the eating disorders. These include marked improvements in the recognition and understanding of the disorders, and the reduction of the morbidity and mortality of anorexia and bulimia nervosa. Bulimia nervosa itself, now the focus of so much attention, was described less than twenty years ago. While these gains, including those in the level of knowledge and appreciation by the public, have been transmitted to the benefit of patients, there remain significant difficulties in treating people with eating disorders. Critical research may address gaps in knowledge and lead to more efficacious treatments. At the same time, however, changes in the health care system are occurring rapidly and these will have an effect on both research and treatment. The purpose of the present article is to highlight scientific and systemic factors that the authors feel will play an important role in how people with eating disorders are responded to in the coming years. In addressing the eating disorders we are confining our remarks to anorexia and bulimia nervosa, and not to obesity; the latter would require consideration of many other issues, beyond the scope of this review.

Objective: To highlight developments in the taxonomy of eating disorders since Russell's original description of bulimia nervosa (BN) in 1979 and through 3 versions of the Diagnostic and Statistical Manual., Method: Criteria for anorexia nervosa (AN), BN and binge eating disorder (BED) are systematically described., Results: While criteria for AN remain largely unchanged between DSM-III-R and DSM-IV, the subclassification of binge/purge and restricter subgroups endorses previous research findings. For BN, the definition of "binge" has occupied considerable attention both in quantitative and qualitative terms. The arbitrary choice of 2 episodes per week as a minimum frequency is also discussed in light of recent data from the Ontario Health Supplement. A third eating disorder, BED, is now included in the appendix of DSM-IV under Eating Disorders--Not Otherwise Specified category. The potential overlap between this disorder and nonpurging BN is discussed. Finally, the relationship between eating disorders and other psychiatric disorders including depression, schizophrenia, obsessional, and conversion disorders is considered as well as the continuum from preoccupation with weight to eating disorder., Conclusion: While significant advances have been made in understanding and classifying eating disorders during the past 15 years, further empirical work is necessary to clarify areas of uncertainty.

Of six bulimic outpatients who completed a double-blind crossover trial with carbamazepine, one patient, who had a history suggestive of bipolar disorder, responded dramatically with cessation of binge eating. This supports a possible link in some patients between bulimia and affective illness.

The current paper reviews the methods used for assessing body image in anorexia nervosa and bulimia nervosa. A major concern in the assessment of body image in the area of eating disorders has been the apparent failure to recognize the complexity of the body image construct. The development of a range of standardized measures of body image has been an important advancement in recent years; however, it would be premature to assume that any of these methods assesses body image in its entirety. Rather, each provides an operational index of one aspect of this multidimensional construct. The relationship between different dimensions of body image and their respective operational measures remains a potentially valuable area for investigation. Few studies have employed multiple measurement techniques and it is recommended that future investigations incorporate convergent measures which tap perceptual, affective and cognitive elements of the broad body image construct. Factors such as reliability and validity of the different measures of body image must be considered in planning studies with eating disorder patients. Reliability is particularly important because it sets an upper limit on validity. Most studies may be criticized for not addressing the validity of measures employed. Concurrent, convergent, discriminant and predictive validity should be demonstrated for existing as well as new methods. The issue of construct validity which remains a more general concern in the area of body image applies to the investigation of eating disorders. There is the danger that 'body image disturbances' become reified based upon group differences on a particular operational measure. Therefore, conclusions must be cautious even when inferences are drawn from measures which appear to have 'face validity'. The literature on body image in eating disorders has expanded rapidly during the past several years. Generally, it has confirmed the clinical impression that these patients display serious distortions in the feelings, attitudes and perceptions related to their bodies. Hopefully, future research will clarify the mechanisms of action of these body image disturbances and provide insights which will lead to improved treatment.

Recent case reports have suggested an association between anorexia nervosa and/or bulimia with insulin-dependent diabetes mellitus (IDDM). Fifty-eight females aged fifteen to twenty-two with IDDM for more than one year were assessed for the presence of eating disorders. Patients were screened for eating and weight pathology using the Eating Disorder Inventory (EDI) and Eating Attitudes Test-26 (EAT-26). Glycosylated hemoglobin (HbA1) was measured to assess metabolic control. Subjects who scored above the cut-off points associated with eating and weight pathology were interviewed. Clinically significant eating and weight pathology was found in 20.7 percent of the population. Of these subjects, anorexia nervosa was found in 6.9 percent and the syndrome of bulimia, based on DSM-III criteria, was found in 6.9 percent. In patients with bulimia, there was a strong inverse correlation between bulimic symptoms and metabolic control. These findings suggest that anorexia nervosa may be more common in female adolescents with IDDM than in nondiabetic populations and that bulimic symptoms may be a risk factor for poor metabolic control.

Psychometric and clinical correlates of the Eating Attitudes Test (EAT) are described for a large sample of female anorexia nervosa (N = 160) and female comparison (N = 140) subjects. An abbreviated 26-item version of the EAT (EAT-26) is proposed, based on a factor analysis of the original scale (EAT-40). The EAT-26 is highly correlated with the EAT-40 (r = 0.98) and the three factors form subscales which are meaningfully related to bulimia, weight, body-image variables and psychological symptoms. Whereas there are no differences between bulimic and restricter anorexia nervosa patients on the total EAT-26 and EAT-40 scores, these groups do indicate significant differences on EAT-26 factors. Norms for the anorexia nervosa and female comparison subjects are presented for the EAT-26, EAT-40 and the EAT-26 factors. It is concluded that the EAT-26 is a reliable, valid and economical instrument which may be useful as an objective measure of the symptoms of anorexia nervosa.

Four groups of bulimic patients with different weights and weight histories were compared on measures of eating and psychological functioning. Results with the Eating Disorder Inventory and Eating Attitudes Test indicated that groups were similar in terms of attitudes toward food, eating and body dissatisfaction as well as other traits which have been identified as relevant to eating disorder patients. Results also indicated that the referral patterns of patients with different weight histories have changed over time; previously, most patients had anorexia nervosa either currently or historically but more recently many patients are presenting with symptoms of equal severity but with no history of anorexia nervosa. It is concluded that diagnostic categories for bulimia formed solely on the basis of weight variables may not be clinically useful.

The purpose of this study was to examine the relationship between bulimia in women with anorexia nervosa and bulimia of a similar severity in normal-weight women and to determine the support for the distinction between these two groups according to DSM-III criteria. Results indicated that bulimic women with anorexia nervosa (N = 59) and bulimic normal-weight women (N = 59) resembled each other on most variables and were more similar to each other than to women with anorexia nervosa who rigidly restricted food intake (N = 59). The results failed to support the diagnostic distinction between bulimia in anorexic women and bulimia of equal severity in normal-weight women.

Thirty-three bulimic and 14 restrictive anorexics were compared on DSM-III diagnoses of affective and anxiety disorders, observer-rated and self-rated measures of depression and anxiety, and family history. A subgroup of 18 eating disorder subjects was administered the dexamethasone suppression test. The same 18 subjects were compared to 13 subjects with affective disorder on the Schedule for Affective Disorders and Schizophrenia. It was found that a large group with bulimia and restrictive anorexia nervosa was subject to a depressive disorder. Thirty-eight percent of the sample fulfilled criteria for a major depressive episode. The dysphoric experience seemed as intense in the bulimic and restricter group. There was a high incidence of dexamethasone nonsuppression (55%), which was found to be related to various measures of depression. Bulimics and restricters differed in their family history of affective disorder. While 61% of bulimics had a positive history of depression, this was found in only 23% of restricters (p less than .03).

General principles for the management of eating disorders are viewed with particular emphasis on correcting disturbed eating and weight within the current cultural context. A range of different therapeutic options are outlined with indications for the integration and sequencing of these as part of a multidimensional model of treatment.

An unselected sample of 46 female adolescents with insulin-dependent diabetes mellitus (IDDM) for more than one year were assessed systematically for the presence of anorexia nervosa and bulimia. These disorders and their partial syndromes were found in 19.5% of this population. Anorexia nervosa and bulimia diagnosed on the basis of DSM-III criteria were each found in 6.5% of the population representing approximately a 6-fold and 2-fold increase respectively in the expected prevalence for similar nondiabetic individuals. Bulimic symptoms were associated with poor metabolic control as reflected in blood levels of glycosylated hemoglobin (HbAl). These findings have important implications both for the pathogenesis of anorexia nervosa and bulimia and for the management of some cases of IDDM with unstable metabolic control.

Bulimia is a poor prognostic sign in anorexia nervosa. This raised the question of whether bulimia represented an "end stage" of chronic anorexia nervosa or whether bulimic patients were a distinct subgroup. All subjects seen by us personally from 1970 to 1978 were included in this study provided they met modified criteria of Feighner et al (1972). Of this group, 68 experienced bulimia and 73 did not (restricters). Bulimic patients had a history of weighing more and were more commonly premorbidly obese. Bulimic patients were those who vomited and misused laxatives. The bulimic group displayed a variety of impulsive behaviors, including use of alcohol and street drugs, stealing, suicide attempts, and self-mutilation. With regard to family history, the high frequency of obesity in the mothers of bulimic patients was noteworthy. The two groups share features common to patients with primary anorexia nervosa. However, these results suggest a different group of women are predisposed to have anorexia nervosa develop with bulimia.

Twenty bulimics, 20 depressives and 20 normal controls were studied using the Dexamethasone Suppression Test (DST) as defined by Carroll et al. Their past psychiatric and family histories were compared. We found that actively bulimic subjects had a rate of DST non-suppression of 20%, and that 20% of them had a past history of a major depressive disorder. Forty per cent had a history of alcoholism and/or antisocial personality in a first degree relative, but only 5% had a positive family history of affective disorder. These rates were significantly lower than those found in the depressed group except for the family history of alcoholism and/or antisocial personality for which there was no significant difference. We identified a subgroup of bulimic DST non-suppressors who, like patients with melancholia, were characterized by past history of major depressive illness and high rates of family history of affective disorder, alcoholism and/or antisocial personality in first degree relatives. This group responded to antidepressant medications in a manner similar to depressed patients.

In an open prospective clinical study, 14 female outpatients with anorexia nervosa or bulimia completed a 6-week trial of isocarboxazid, with a mean dose of 34 mg. The eight bulimic and six restrictive anorexic subjects did not show any significant differences in medication response. Ratings of depression and anxiety showed significant improvement after the fourth week. Significant improvement in eating behavior, as measured by the number of meals missed per day, was noted. For the bulimic subgroup, bingeing and vomiting showed a nonsignificant reduction, while the urge to binge was significantly reduced. There was no significant weight change in either group during the study, although the restrictive group had gained substantially at 6-month follow-up.