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Stress has been supposed to increase appetite. The biological basis of this phenomenon may be a stress-induced alteration of the secretion of GUT peptides such as ghrelin. Stress-induced changes in ghrelin secretion could be a biological basis of overeating and a factor contributing to the development of obesity. Aim of the study was to analyze the effect of acute psychosocial stress on ghrelin secretion in obese and normal weight women. We compared pre- and postprandial plasma ghrelin secretion of 42 obese and 43 normal weight women in a randomized crossover design. Ghrelin and cortisol concentrations were measured and ratings of stress were also recorded in response to a psychological stressor (Trier Social Stress Test, TSST). Ghrelin samples were collected in the fasting state one time before participating in the TSST and one time before a control session. After the TSST, respectively, control session participants had a standardized ad libitum meal. 30 and 60 min after the TSST, respectively, control session preprandial ghrelin was measured again. Obese women showed lower pre- and postprandial release of ghrelin than normal weight controls. Moreover, obese women showed inhibited postprandial decrease of ghrelin secretion. Stress did not affect postprandial ghrelin secretion, but inhibited food intake in all subjects. The present data provide further evidence of altered ghrelin release in obesity. Acute stress did not affect postprandial ghrelin secretion, but inhibited food intake in all subjects. Results are discussed with regard to biological and psychological regulation of hunger and satiety in obesity.

Stress-related cortisol secretion has been linked to increased appetite and subsequent food intake in overweight individuals. The present study addresses this relationship in a repeated-measures randomized controlled laboratory experiment. Nineteen obese women were compared to 36 normal weight controls with respect to stress-induced salivary cortisol and laboratory eating behavior, measured by a universal eating monitor. The trier social stress test served as stressor. Stress-induced cortisol levels were significantly higher in the obese compared to the normal weight controls. Unexpectedly, a corresponding increase in laboratory food intake was not detected. The results are interpreted and discussed with regard to restrained eating, which was found to be present to a significant degree in the obese women.

The impact of stress on circulating levels of appetite-regulating hormones remains largely unknown. The aim of this study was to analyze the effect of acute psychosocial stress on the gut hormone peptide YY (PYY) secretion in obese and normal weight women. Therefore, we compared pre- and post-prandial plasma PYY secretion of 42 obese and 43 normal weight women in a repeated measure randomized controlled laboratory experiment. PYY and cortisol concentrations were measured and ratings of stress and satiety were also recorded in response to a psychological stressor (Trier Social Stress Test, TSST). PYY samples were collected in the fasting state both before participating in the TSST and before a control session. Participants had a standardized meal after the TSST and control session, respectively. PYY was measured both 30 and 60 min after the TSST and control session, respectively. Stress inhibited PYY secretion as well as food intake in all women, but did not influence subjective satiety perception. The present data indicate that despite of lower PYY levels the subjects' requirement to overeat was not increased. From an evolutionary perspective this finding is adaptive. After stress the organism is prepared for fight or flight reaction, whereas not primarily necessary functions are inhibited. Therefore, increased food intake during stress would be dysfunctional.

Negative emotions have been hypothesised to trigger a short-term eating pattern in the obese that leads to a high calorie intake. The present study induced emotions of different quality (negative, neutral, positive) and compared laboratory eating behaviour in overweight and normal weight children. No significant emotion related differences in cumulative food intake curves during a laboratory meal were found. Results point to an adequate regulation of hunger and satiety in children, which possibly cannot be maintained during adulthood.

Sex differences in treatment response have been observed in overweight children. The present study therefore investigated differences in 52 boys and girls before treatment, with respect to laboratory eating characteristics, measured with a universal eating monitor. Differences were obtained for average eating rate (p<0.01), frequency of spoonfuls (p<0.01), and a trend for differences was seen for initial eating rate (p<0.10). The results point to the necessity of specific treatment elements for boys to modify their unfavourable microstructure of intake.

Aim of the study was to compare the microstructural eating behavior of obese patients with and without binge eating disorder (BED) after stress induction in laboratory. Seventy-one female subjects were investigated (mean BMI 36.9). Thirty-five fulfilled criteria for BED. A 2×2 factorial design with repeated measurement (stress vs. no stress) on the second factor was applied. Stress was induced by the Trier Social Stress Test (TSST) and chocolate pudding served as laboratory food. Variables of eating behavior were measured by a universal eating monitor (UEM). Only in participants with BED stress was associated with an increase in the initial eating rate and a diminished deceleration of eating at the end of the meal. Generally, BED subjects ate with larger size of spoonfuls during the laboratory meal than non BED controls. The eating behavior of obese patients with binge eating disorder seems to be significantly affected by stress. The stress-induced eating behavior of BED patients is characterized by a stronger motivation to eat (indicated by a fast initial eating rate) as well as by a lack of satiety perception (indicated by less deceleration of eating rate)., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective: To compare the microstructural eating behavior of obese patients with and without binge eating disorder (BED) after stress induction in laboratory., Method: Forty-eight obese women were investigated. Seventeen were assigned to the group of BED. Group (BED vs. non-BED) by condition (stress vs. no stress) interaction effect on feeding variables, measured by a universal eating monitor, was tested. Stress was induced by the trier social stress test (TSST) and chocolate pudding served as laboratory food., Results: From the nonstress to the stress condition, patients with BED, when compared with non-BED had a greater increase in average eating rate (p < .01) and a corresponding greater increase in the frequency of spoonfuls (p < .02). The BED group also showed a different change in acceleration/deceleration from the nonstress to the stress condition compared to the non-BED group (p < .04)., Discussion: Obese individuals with BED appear to exhibit a different response to stress than obese non-BED individuals and individuals with bulimia nervosa.

Restrained eating involves a mainly cognitive control of eating behaviour and has been supposed to be a predisposing factor for the development of eating disorders. Biological correlates of the behaviour are expected, too. The present study investigated resting metabolic rate in 33 female restrained and unrestrained eaters. Measured by indirect calorimetry RMR showed a significant negative relationship to the degree of dietary restraint (controlled for BMI, partial r=-.46, p<.01). The lower energy requirements of restrained eaters might be genetically predisposed, but also might have severe consequences in nonclinical and clinical groups.

The eating behavior of 49 obese and 47 normal weight controls of both sexes was compared in laboratory. A universal eating monitor according to the Kissileff-instrument was used to obtain cumulative intake curves with chocolate pudding as laboratory food. Compared to controls the obese had a significantly higher initial eating rate (p<.002), larger spoonfuls (p<.005), and a greater total intake (p<.03) for the laboratory food. For initial eating rate a significant sex x weight interaction was found (p<.04). Higher values for males emerged only for overweight, but not for normal weight subjects. On the one hand, these data suggest an eating behavior of obese, which will promote a high energy intake in the natural environment. On the other hand, the observed differences can also be interpreted as a consequence of cognitive factors, impacting the eating behavior of obese under specific conditions.

We investigated a possible association between attention-deficit/hyperactivity disorder (ADHD) and overweight by measuring weight status and energy expenditure (basal metabolic rate, BMR) in 39 ADHD-boys with hyperactivity (mixed hyperactive/impulsive and inattentive or predominantly hyperactive/impulsive) and 30 healthy boys. The age range for the total group was 8-14 years. Weight and height were measured by a calibrated scales and stadiometer. Body mass index standard deviation scores (BMI-SDS) were calculated. BMR was determined by indirect calorimetry. Significant differences were obtained between the ADHD- and the control-group, but not between ADHD-subgroups. Both BMI-SDS and BMR were higher in the group of ADHD-boys, whereby the differences were more marked when they were older. More overweight and obese subjects were found in the ADHD-sample. Impulsive behavior in ADHD-boys with hyperactivity may lead to an increased food intake, which is then likely to overcompensate the heightened energy expenditure.

The universal eating monitor (UEM) of Kissileff for laboratory measurement of food intake was modified and used with a newly developed special software to compute cumulative intake data. To explore the measurement precision of the UEM an investigation of test-retest-reliability of food intake parameters was conducted. The intake characteristics of 61 normal weight males and females were measured repeatedly in the laboratory with a measurement interval of 1 week. Yogurt of preferred flavor served as test meal. Test-retest-reliability of intake characteristics ranged from .64 (number of bites) to .83 (bite-size) and was .73 for initial eating rate, but only .16 for change of eating rate. Sex, BMI and eating habits according to TFEQ-factors had no significant effects on reliability of intake characteristics. The retest-reliability for all but one of the laboratory intake measures is comparable to standards of personality questionnaires and seems not to be influenced by sex or trait characteristics of eating behavior.

Objective: To determine parental influences on obesity, the eating behavior of 80 obese and normal weight children (aged 8-12 years) was investigated in the laboratory., Method: A controlled repeated measures design was used. The mother was either present or absent while the child was eating in the laboratory. The eating style was measured by recording cumulative eating curves with a universal eating monitor, using yoghurt as a standardized experimental meal., Results: The eating behavior of obese children differed significantly from normal weight children only when the mother was present in the laboratory. Overweight children ate faster with larger bites and showed an acceleration of their eating rate toward the end of the meal., Discussion: Such an eating style can be hypothesized to explain an increased calorie intake in obese children, promoting a positive energy balance in the long term. The data support a learning model of obesity in childhood, which also has implications for family treatment., (Copyright 2001 by John Wiley & Sons, Inc.)

The relationship between restrained eating and leptin levels 6 months later was investigated. Twenty obese girls, ages 8-12 years, were studied. Degree of restrained eating was assessed with the Three-Factor Eating Questionnaire. Serum leptin levels were determined 6 months after the measurement of cognitive restraint. Restraint score and leptin levels showed a significant negative correlation (r = -0.43) The correlation was also significant when controlling for fat mass (r = -0.61), which is the strongest biological predictor of leptin levels. If lower leptin levels cause a diminished energy expenditure, then paradoxically, restrained eating might be responsible for weight gain in obese individuals because of its promotion of a positive energy balance.

The objective was to investigate metabolic (resting metabolic rate), behavioral (energy intake), and endocrine variables (fasting insulin and growth hormone levels) potentially responsible for a positive energy balance in obese children in a cross-sectional study. The study was in 25 obese children aged 8 to 12 years and 21 nonobese children of the same age range. Weight, height, lean body mass (LBM) and fatmass (FM) were measured by bioelectrical impedance analysis, resting metabolic rate (indirect calorimetry) for the duration of 25 min, 7-day food records and fasting levels of insulin and human growth hormone (HGH). In the total sample, no differences were found in resting metabolic rate (RMR controlled for differences in weight) and energy intake between groups, whereas fasting insulin level was significantly higher and basal growth hormone concentration was significantly lower in the obese children. In RMR, there were significant age-dependent differences only in 10-year-old children, with the obese subjects showing lower values. The results fit in a multidimensional model, taking into account a critical period in prepubertal age for the development of childhood obesity. This period may be characterized by a reduced RMR, which results in an increased body weight, even if there is no excessive energy intake.

The eating disorder bulimia nervosa is characterized by alternating periods of strict dieting and overeating. Patients also report mood fluctuations, frequent eating related thoughts, fear of loss of control over eating, impairment of cognitive abilities such as concentration, and somatic complaints. The present study attempted to clarify to what extent these symptoms are consequences of the dieting behavior. Nine healthy young women, classified as unrestrained eaters, were set on a intermittent dieting schedule over 4 weeks. Four days each week (Tue, Wed, Thu, Fri) they had to reduce their intake below 600 kcal/day, the other 3 days they could eat without restrictions. Psychological variables were assessed by means of a standardized diary. Biological indices of starvation were also measured repeatedly. There was no substantial weight loss after the 4 weeks, although subjects had significantly increased levels of beta-hydroxybutyric acid during the dieting periods, and decreased levels of t3 after 2 weeks. The reported tendency to overeat and the actual calorie intake during the days of unlimited access to food showed a significant increase over the 4-week period. Eating-related thoughts, feelings of hunger, and fear of loss of control were significantly more frequent during periods of dieting, compared to days of normal eating. Subjects also reported worse mood, heightened irritability, difficulties concentrating, and increased fatigue. These results suggest that a substantial part of symptoms of bulimic patients might be associated with the frequent periods of an extremely restrained eating behavior.

Elevated plasma levels of cortisol, as well as deficits in cognitive processes such as attention, have been observed in patients with eating disorders. The association between plasma cortisol and performance in vigilance task was studied in 17 patients with bulimia nervosa or anorexia nervosa during the acute phase of their eating disorder. In comparison to normal young women, the patients had a significantly lower hit rate in a discrimination task and showed an impaired perceptual sensitivity index. They also displayed significantly longer reaction times to hits, but not to false alarms. Cortisol levels of the patients were significantly higher than those of the normal controls. When patients were divided according to their median cortisol level, the patients with higher levels performed significantly more poorly than did the patients with lower levels. In the total patient sample, cortisol levels showed a significant negative correlation with hit-rate (r = -.54) and a significant positive correlation with reaction time to hits (r = .70). Other clinical characteristics were not related to cognitive performance. These results suggest a possible role of cortisol in the development of attentional deficits in eating disorder patients.

Twenty-two normal weight women with bulimia nervosa (BN) were studied (mean age, 25 +/- 5 yr; body mass index, 20.2 +/- 2.6 kg/m2). Sixteen of them reported menstrual cycles in the range of 21-42 days, and 6 had experienced absence of menstruation for at least 3 months. Twenty-one healthy women with regular menstrual cycles (mean age, 23 +/- 2 yr; body mass index, 20.7 +/- 1.4) served as the control subjects. Frequent morning blood samples for estradiol (E2) and progesterone (P4) determinations were obtained for the duration of 1 menstrual cycle or for 6 weeks in the case of amenorrhea. LH, FSH, cortisol, and insulin secretion were studied on day 3, 4, or 5 after the onset of a menstrual cycle or on a random day in the 6 BN women with amenorrhea. Blood samples were collected at 15-min intervals from 1800-0600 h for LH and FSH and at 30-min intervals from 2400-0600 h for cortisol and insulin. Nineteen of the 21 controls, but only 10 of the 22 BN women, fulfilled the following standard criteria: maximum E2 above 440 pmol/L, maximum P4 above 19 nmol/L, and luteal phase length of 9 days or more. The 10 BN women with normal menstrual cycles had lower mean insulin concentrations than the controls (70 +/- 20 vs. 120 +/- 30 pmol/L; P less than 0.01), but gonadotropin secretion, cortisol, and T3 concentrations were similar. The 8 BN women with amenorrhea or ovulatory dysfunction (maximum E2, less than 440 pmol/L; maximum P4, less than 6 nmol/L) displayed decreased mean LH pulse frequency (2.6 +/- 2.4 vs. 5.7 +/- 2.0 pulses/12 h; P less than 0.01), increased mean cortisol (120 +/- 40 vs. 80 +/- 20 nmol/L; P less than 0.01), decreased mean insulin (90 +/- 40 vs. 120 +/- 30 pmol/L; P less than 0.05), and decreased mean T3 concentrations (1.5 +/- 0.3 vs. 1.8 +/- 0.2 nmol/L; P less than 0.01). The data suggest that BN in normal weight women is associated with an increased rate of ovarian dysfunction; decreased pulsatile LH secretion seems to be an important mechanism. Increased cortisol in the disturbed subgroup indicates that activation of the hypothalamic-pituitary-adrenal axis may play a role in the pathogenesis of gonadal dysfunction in bulimia nervosa.

Objective: To examine the association of different types of everyday eating behavior with disturbances of menstrual function., Design: Prospective cohort study with two groups, low dietary restraint (n = 13) and high dietary restraint (n = 9), identified with the Three-Factor Eating Questionnaire by Stunkard and Messick., Setting: Research clinic., Participants: Normal volunteers (students and young professionals)., Interventions: None., Main Outcome Measures: Frequent serum and urine samples for determination of estradiol (E2), progesterone (P), and metabolites. Food and behavioral diaries., Results: Eleven of the 13 women with low dietary restraint had menstrual cycles that fulfilled the following standard criteria: Serum E2 maximum of 440 pmol/L or more, P maximum of 19 nmol/L or more, and luteal phase length of 9 days or more. Only 2 of the 9 women with high dietary restraint had cycles that satisfied these criteria. Of the remaining 7, 1 had an anovulatory cycle and 6 had decreased P concentrations (P less than 0.05) and/or a shortened luteal phase (P less than 0.02)., Conclusions: High cognitive restraint in everyday eating behavior may be a risk factor for the development of menstrual disturbance in young women.

In a comparison of nutritional management (NM) and stress management (SM) for treatment of bulimia nervosa, 55 female patients were randomly assigned to either treatment. Therapy consisted of 15 sessions in a group over three months, by the end of which, patients under both treatment conditions showed a significant reduction in the frequency of binge eating and vomiting and a significant improvement in various psychopathological features such as body dissatisfaction and depression. All improvements were maintained over 12-month follow-up NM produced a more rapid improvement in general eating behaviour, a faster reduction in binge frequency and a higher abstinence rate from binge eating. SM led to greater positive changes in certain psychopathological features such as feelings of ineffectiveness, interpersonal distrust and anxiety. NM should be regarded as a necessary first intervention in all bulimic patients. Further psychological therapy, such as SM, is indicated as well for some patients, depending on their specific psychological difficulties.

Insulin, glucose, and large neutral amino acids (LNAA) were studied in 10 patients with anorexia nervosa, 13 patients with bulimia nervosa, and 15 healthy controls. Blood samples were collected at hourly intervals during the day and at two-hour intervals during the night over a 24-hour period. Ad libitum caloric and relative carbohydrate intake was significantly reduced in the anorectic and bulimic patients. Elevated concentrations of beta-hydroxybutyric acid (BHBA) were seen in the bulimic group, and low triiodothyronine (T3) concentrations in the anorectic group. Mean plasma glucose and insulin concentrations were significantly lowered in both groups. The tryptophan (Trp) to LNAA ratio was reduced in anorectic, but not in bulimic patients. These findings suggest that Trp influx into the brain is reduced in anorectic patients, possibly impairing central serotonergic function.

The effects of 19 meals of different caloric content on slides on palatability and hypothetical duration of consumption were investigated in 7 patients with anorexia nervosa, 17 patients with bulimia nervosa at the beginning and after 8 weeks of hospital treatment. Nine healthy females served as controls. At the beginning of treatment, palatability of low caloric food was significantly higher and hypothetical duration of consumption of high caloric food was significantly longer in patients when compared to controls. After 8 weeks, in the patients palatability of low caloric food had decreased. Dislike for high caloric food remained stable in anorexics.

Thirty-one young female athletes and 13 age-matched sedentary controls were studied throughout one menstrual cycle or over a 6 week period. Blood was sampled on 5 days per week. Episodic gonadotrophin secretion was measured in the early follicular phase and in the late luteal phase by blood sampling over a 12-h period at 15-min intervals. Eight athletes had anovulatory cycles, nine had impaired progesterone (P4) secretion during the luteal phase and 14 had normal cycles as judged from oestradiol (E2) and P4 plasma levels. Athletes with normal cycles had shorter cycles, lower E2 maxima at midcycle, and lower E2 and P4 concentrations during the luteal phase than had sedentary controls. Episodic luteinizing hormone (LH) secretion in the early follicular phase was significantly impaired in the anovulatory athletes: the average LH values over 12 h and the number of secretion episodes were significantly reduced. No significant changes were seen in follicle stimulating hormone secretion.

Restrained (n = 9) and unrestrained eaters (n = 13) were selected from a group of healthy young women. Blood samples were collected overnight at half-hour intervals. Levels of cortisol, growth hormone, and glucose in both groups did not differ, while restrained eaters had significantly lower insulin values. After a standardized test meal of 500 kcal, restrained eaters had significantly lower norepinephrine values while insulin and glucose values did not differ from those of the unrestrained group. These findings indicate that restrained eating may have a biological basis.

In 17 female recreational athletes, ovarian function was monitored using daily hormone measurements and serial ultrasound determinations. Whereas 11 out of 13 women of a control group showed estradiol (E2) maxima beyond 470 pmol/l, progesterone (P4) maxima of 19 nmol/l or more, and a luteal phase length of 9 days or more, only 10 out of 17 athletes satisfied these criteria. Six athletes showed disturbed follicular development, and one athlete showed luteal phase disturbance. Both athletes with disturbed menstrual function (n = 7) and athletes fulfilling the above-mentioned minimal criteria (n = 10) had lower E2 concentrations in all phases of the menstrual cycle (P less than 0.05). P4 concentrations were significantly decreased in the group with disturbed menstrual function (P less than 0.05). Maximal aerobic capacity in the two athlete groups was similar. Neither athlete group showed the expected increase in caloric intake compared with the sedentary controls. It is concluded that recreational running is associated with altered ovarian function. Inadequate nutritional adaptation may be a contributing factor.

Reported frequency of consumption for certain food items was studied in young normal-weight women, classified into 19 unrestrained and 20 restrained eaters by the Three-Factor Eating Questionnaire of Stunkard & Messick (1985). Neither group differed in the consumption of basic foods and snacks but restrained eaters showed a strong tendency to avoid fat. A large percentage of this group was used to consuming artificial sweeteners and other calorie-reduced foodstuffs. These qualitative alterations in the everyday eating behavior of restrained eaters may be one of the links between dietary restraint and binge eating.

Significant emotional and physical symptoms have been linked to hormonal changes during the menstrual cycle. A critical evaluation of the available studies questions the commonly held belief in menstrual-cycle-related complaints in the majority of normal women. The present study investigated changes in mood, somatic complaints and vegetative variables during the menstrual cycle in 30 healthy young women. Normal cycle function was evaluated and cycle phases were defined according to endocrine data. For all subjects, blood samples were taken at least three times a week to measure estradiol and progesterone. Daily ratings of psychological variables revealed no significant changes in global mood or depression over the cycle. Somatic complaints such as abdominal pain and breast tenderness were significantly related to the luteal, premenstrual, and menstrual phases. Appetite increased in the periovulatory and premenstrual phases. There was a tendency for sexual interest to be highest in the post-menstrual period. Affect and vegetative variables showed no association with hormone levels but were significantly correlated with subjective stress ratings. We conclude that in most healthy young women, cycle-related hormone fluctuations are not accompanied by marked affective changes. Specific physical complaints, however, do occur, particularly in the luteal, premenstrual, and menstrual phases.

The relationship between depressive symptoms and starvation, reflected by body weight and biochemical parameters, was investigated in 64 patients fulfilling DSM-III criteria for anorexia nervosa or bulimia. Multiple regression analysis revealed significant effects of body weight and beta-hydroxybutyric acid, respectively, on such specific depressive symptoms as depressed or dysphoric mood when controlling for severity of psychopathology of the eating disorder.

The hypothesis that patients with bulimia nervosa and restrained eaters exist on a simple continuum of psychopathology was tested in 60 Ss (20 bulimics, 20 restrained eaters, 20 unrestrained eaters). Regarding measures related to dieting behavior and physical appearance, the restrained eaters differed significantly from unrestrained eaters and were similar to bulimic patients except for level of psychopathology. The restrained eaters could not be distinguished from the unrestrained eaters with regard to measures representing interoceptive perception, depression, self-esteem, and fears about interpersonal relationships. On these traits, bulimic patients could be clearly distinguished from the normal Ss. The results support a 2-component model of the psychopathology of bulimia nervosa.

The construct validity of Herman and Polivy's Restraint Scale (RS), the restraint factor of the Three Factor Eating Questionnaire (TFEQ-R), and the restraint scale of the Dutch Eating Behavior Questionnaire (DEBQ-R) were investigated by relating these scales to self-reported mean caloric intake per day and to other measures associated with disordered eating and figure consciousness. A factor analysis showed that the three restraint scales measure different components of the restraint construct. A high score on the RS was closely related to consequences of mostly unsuccessful dieting, such as disinhibited eating and weight fluctuations, but not to successful overall caloric restriction in everyday life. High scores on the TFEQ-R and the DEBQ-R represented the more successful dieting behavior component of restraint. The three scales have in common a motivational component of restrained eating, including concerns about shape and weight, and desire for thinness.

Preliminary results are reported on the efficacy of a 4-month group (n = 8) therapy compared with waiting-list controls (n = 9) in women with DSM-III bulimia. Treatment consisted of a standard behaviorally oriented stress management program and of basic nutritional management. A significantly greater decrease in binge frequency and specific psychopathology was found in the treated compared with the waiting-list group. The treated subjects showed further improvement 3 months after treatment termination. The usefulness of the different treatment components is briefly discussed.

The relationship between mood and noradrenergic activity, measured by orthostatic norepinephrine response (delta NE), was investigated in 24 patients with anorexia nervosa during inpatient treatment. Mood and delta NE correlated significantly at four out of five measurement points. Group comparisons identified significantly worse mood in patients with pathologically low delta NE values. Thus, biological consequences of altered eating behavior may also affect such psychological symptoms as depressed mood.

DSM-III lifetime diagnoses were assessed in 52 patients with a lifetime history of anorexia nervosa or bulimia by means of a standardised diagnostic interview. It was found that 44.2% had a lifetime diagnosis of DSM-III major affective disorder, with abstaining anorectics having a lower rate of depression than those with bulimic symptoms. In the great majority of cases, the onset of affective disorder post-dated the onset of the eating disorder by at least one year. In patients whose eating disorder was in remission, the rate of depressive symptoms was lower than in those in the acute stage of their illness. These findings, combined with recent studies on biological changes in eating disorders, and psychological theories of depression, suggest that in most cases in which the two conditions are associated, the depression is secondary to the eating disorder.

Although the relevance of single-case methodology for clinical research is stressed frequently in the literature, clinicians do seldom use this approach. The present contribution is an attempt to stimulate and exemplify the realization of single-case designs clinical settings. In the first part of this paper single-case designs and strategies of statistical analysis for practical use are discussed. In the second part three empirical studies are reported: (1) An A/B-design for evaluation of a relaxation program for treatment of chronic headache; (2) an A/B/A/B-design to analyze the effect of cognitive-behavioral treatment in anxiety; and (3) an A/B/C/B/C-desing to test psychological treatment in rehabilitation of a schizophrenic patient.

Blood was obtained three times a week throughout one menstrual cycle or during a 6-week period from 15 patients with bulimia nervosa and from 10 healthy age-matched controls. Of the patients, three had amenorrhoea, eight had oligomenorrhoea and four had regular cycles. Normal follicular development, as judged from continuously low oestradiol (E2) values (less than 120 pg/ml or less than 440 pmol/l), did not occur in seven patients. Compared to patients with increasing E2 values (greater than 120 pg/ml), these seven had a significantly lower body weight. Among the eight patients showing follicular development (E2 greater than 120 pg/ml), four reported regular cycles, but only three developed normal plasma progesterone (P4) values during the luteal phase (P4 greater than 3 ng/ml or greater than 9.5 nmol/l). The luteal phase was of normal length in only one bulimic patient.

The relationship between ventricular size, as a measure of brain atrophy, and performance on a vigilance task was investigated in 39 patients with anorexia or bulimia nervosa during the acute stage of their illness. Compared to normal controls, the patients performed significantly more poorly in the cognitive task. Half of the patients displayed enlarged ventricles. However, the patients with ventricular dilatation did not perform worse in the cognitive test than patients with normally sized ventricles. Other clinical characteristics, such as symptom severity or duration of illness, were also not correlated with ventricular size. These results support the interpretation that cerebral atrophy per se does not have severe consequences on the neuropsychological or psychopathological status in eating disorder patients.

Thirteen healthy, normal weight young women were studied throughout a control cycle and a diet cycle, during which they lost 1 kg per week on a vegetarian 800 kcal diet. Blood was sampled daily in the morning, and at weekly intervals, collected at 10-minute intervals for 6 hours. Follicle growth was monitored by ultrasonic measurement. All subjects showed normal cyclic gonadal function during the control cycle. Cyclic gonadal function remained unaltered in two subjects during the diet cycle. No dominant follicle developed in seven others, while another four showed apparently normal follicular development but impaired progesterone secretion by the corpus luteum. Comparison of both cycles revealed that episodic luteinizing hormone (LH) secretion during the follicular phase was altered by dieting. Average LH concentrations and the frequency of episodic secretions were significantly reduced during the follicular phase but not during the luteal phase. Follicle-stimulating hormone was unaltered.

We tested the hypothesis that disturbed follicular development and disturbed luteal progesterone (P4) secretion are associated with reduced gonadotropin secretion in the early follicular phase by measuring pulsatile LH and FSH secretion at that time in 53 normally menstruating women. Three groups of women were identified on the basis of serum sex steroid concentrations (measured daily throughout the cycle) and luteal phase length. Group A (n = 27) had normal ovarian hormone secretion with peak serum estradiol (E2) concentrations of 440 pmol/L or more, peak serum P4 concentrations of 19 nmol/L or more, and luteal phase length of 9 days or more. Group B (n = 16) had normal peak serum E2 values, but peak serum P4 values less than 19 nmol/L and/or luteal phase length less than 9 days. Group C (n = 10) had peak serum E2 values below 440 pmol/L. Risk factors for the disturbances found in groups B and C were exercise and/or intermittent dieting. Compared to group A, both groups B and C had reduced mean serum LH concentrations (3.1 +/- 1.5 vs. 2.3 +/- 1.4 and 2.0 +/- 1.0 IU/L; P less than 0.05) and reduced LH pulse frequencies (5.2 +/- 2.1 vs. 3.5 +/- 1.8 and 3.3 +/- 2.3 pulses/12 h; P less than 0.02). LH amplitude was similar in all 3 groups. Mean serum FSH concentrations were slightly but not significantly lower in group C. We conclude that reduced gonadotropin secretion during the follicular phase may indeed affect E2 and P4 secretion at later stages of the menstrual cycle. The patterns of alteration associated with disturbed E2 and P4 secretion in normally menstruating women are similar to those that occur in women with hypothalamic amenorrhea.

Based on laboratory results, restrained eating has been linked to the development of binge eating and eating disorder syndromes such as bulimia nervosa. This study was designed to extend the scope of investigation of the concept of restrained eating beyond the laboratory. Eating behavior and biochemical indices of nutritional state were investigated in 60 young women, who were divided in restrained and unrestrained eaters by questionnaire. Seven-day records of food intake showed that the high-restraint group ate around 400 kcal a day fewer than the low-restraint group. Group differences in actual macronutrient intake and long-term food preferences pointed to a qualitatively altered eating pattern in restrained eaters. Actual protein portion was higher in restrained eaters. They tried to avoid calorie dense food items of high carbohydrate and fat content. Instead, they preferred food regarded as low-caloric and healthy. Plasma levels of triiodothyronine and glucose, which could be taken as indices of long-term adaptation to starvation, were not decreased in the high-restraint group. However, significantly higher levels of triglycerides in restrained eaters may reflect a biological state due to short-term starvation. The results indicate that the concept of dietary restraint predicts eating behavior not only under experimental conditions, but also in normal life. As a consequence of altered eating patterns, psychological and physiological deprivation can be hypothesized in restrained eaters, making them prone to the occurrence of overeating.

A proportional hazards model was used to analyze effects of sociodemographic variables on length of hospital stay in psychiatric patients. Marital status and socioeconomic status had a significant influence in psychotic patients, but not in neuroses. A significant time dependency of hazard rate was also found.