Binge Purging Research Articles

Thin healthy women have a similar low bone mass to women with anorexia nervosa

An association between anorexia nerviosa (AN) and low bone mass has been demonstrated. Bone loss associated with AN involves hormonal and nutritional impairments, though their exact contribution is not clearly established. We compared bone mass in AN patients with women of similar weight with no criteria for AN, and a third group of healthy, normal-weight, age-matched women. The study included forty-eight patients with AN, twenty-two healthy eumenorrhoeic women with low weight (LW group; BMI < 18.5 kg/m2) and twenty healthy women with BMI >18.5 kg/m2 (control group), all of similar age. We measured lean body mass, percentage fat mass, total bone mineral content (BMC) and bone mineral density in lumbar spine (BMD LS) and in total (tBMD). We measured anthropometric parameters, leptin and growth hormone. The control group had greater tBMD and BMD LS than the other groups, with no differences between the AN and LW groups. No differences were found in tBMD, BMD LS and total BMC between the restrictive (n 25) and binge-purge type (n 23) in AN patients. In AN, minimum weight (P = 0.002) and percentage fat mass (P = 0.02) explained BMD LS variation (r2 0.48) and minimum weight (r2 0.42; P = 0.002) for tBMD in stepwise regression analyses. In the LW group, BMI explained BMD LS (r2 0.72; P = 0.01) and tBMD (r2 0.57; P = 0.04). We concluded that patients with AN had similar BMD to healthy thin women. Anthropometric parameters could contribute more significantly than oestrogen deficiency in the achievement of peak bone mass in AN patients.

Food cravings discriminate between anorexia and bulimia nervosa. Implications for “success” versus “failure” in dietary restriction

Food cravings are subjective, motivational states thought to induce binge eating among eating disorder patients. This study compared food cravings across eating disorders. Women (N=135) diagnosed with anorexia nervosa, restrictive (ANR) or binge–purging (ANBP) types, or bulimia nervosa, non-purging (BNNP) or purging (BNP) types completed measures of food cravings. Discriminant analysis yielded two statistically significant functions. The first function differentiated between all the four group pairs except ANBP and BNNP, with levels of various food-craving dimensions successively increasing for ANR, ANBP, BNNP, and BNP participants. The second function differentiated between ANBP and BNNP participants. Overall, the functions improved classification accuracy above chance level (44% fewer errors). The findings suggest that cravings are more strongly associated with loss of control over eating than with dietary restraint tendencies.

Anorexia nervosa: from purgative behaviour to nephropathy. a case report

BackgroundIndividuals who suffer from Anorexia Nervosa refuse to maintain a minimally normal body weight, are intensely afraid of gaining weight and exhibit a significant disturbance in the perception of the shape and size of their body. Postmenarchal females with this disorder are amenorrohic. In the Binge-Eating/Purging subtype individuals regularly engage in binge eating and purging behaviour (i.e self-induced vomiting or misuse of laxatives, diuretics, or enemas).Hypokalaemia is often seen in chronic Anorexia Nervosa, especially that of the purging type (ANp), and, as well as electrocardiographic anomalies, this can lead to tubulointerstitial nephritis (hypokalaemic nephropathy) with typical histological characteristics. The physiopathological mechanisms behind this damage are linked to altered stimulation of vasoactive mediators, and to the ammonium-mediated activation of the alternative complement pathway. However, it has not yet been ascertained whether a variant of the pathway specific for ANp [1], exists.Case presentationWe describe herein a case of hypokalaemic nephropathy in a patient affected by chronic ANp who presented to our Centre for Eating Disorders.ConclusionHypokalaemia can provoke cardiovascular alterations as well as muscular and renal complications, and thus potential renal damage needs to be investigated in patients suffering from long-term purgative anorexia.

Dissociation in the Binge–Purge Cycle of Bulimia Nervosa

ABSTRACT Objective: This study focused on whether those suffering from bulimia nervosa may experience dissociative symptoms in relation to bulimic behavior rather than as a general pattern. Method: In this study, which used an experience sampling methodology, 12 adult women who met Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria for bulimia nervosa completed questionnaires measuring state levels of dissociation during 5 sequential binge–purge cycles and at a random time not associated with bingeing or purging. Results: Participants did experience dissociative symptoms, which were higher during bingeing and purging. Dissociation varied within the binge–purge cycle, rising throughout the cycle until after the purge, then declining slightly. Conclusion: Women with bulimia nervosa reported experiencing higher levels of dissociative symptoms during binge–purge episodes, and dissociative symptoms returned to normal levels after completion of the purge. These data support the idea that bulimia nervosa is associated with dissociation, but that the dissociative symptoms are expressed most dramatically during binges. They are also supportive of models of bingeing as an escape.

Illness intrusiveness in anorexia nervosa

Objective “Illness intrusiveness” refers to illness-induced lifestyle disruptions. The primary aim of the current study was to compare the level of illness intrusiveness in anorexia nervosa (AN) to that reported in a variety of other chronic medical and psychiatric conditions. A secondary aim was to compare the two subtypes of AN (binge/purge vs. restricting) in terms of the nature and extent of illness intrusiveness. A final goal was to examine changes in the level of illness intrusiveness in AN following successful completion of specialized inpatient treatment. Methods The participants were a consecutive series of 121 female inpatients with AN who were admitted to a specialized inpatient unit for treatment of the eating disorder. Assessments took place before and after inpatient treatment and at 3-month follow-up. Results At baseline, illness intrusiveness scores for AN patients were significantly higher than those reported by women in the medical and psychiatric comparison groups. Overall, illness intrusiveness scores decreased (i.e., improved) significantly following successful completion of inpatient treatment. Among patients with the restricting subtype, scores continued to improve during follow-up, whereas this was not the case among patients with the binge–purge subtype of AN, whose scores did not change significantly during follow-up. Conclusion Despite being notoriously ambivalent about change, these findings suggest that AN patients perceive their illness to be highly disruptive to a variety of life domains, even more so than patients with other chronic medical and psychiatric conditions.

Reduced platelet [ 3H]paroxetine binding in anorexia nervosa: Relationship to eating symptoms and personality pathology

Alterations in serotonin function have been implicated in both anorexia and bulimia nervosa, and previous studies suggest associations between serotonin function and variations in pathological personality traits. Women meeting DSM-IV criteria for anorexia nervosa (AN, 16 with the restricting subtype and 14 with the binge–purge subtype) and 49 healthy control women (CW) provided blood samples for analyses of platelet [ 3H]paroxetine binding. Participants also filled out questionnaires tapping eating disorder symptoms, depression, and personality pathology. Compared with CW, women with restricting and binge–purge AN had significantly lower levels of paroxetine binding (respectively: 1012 + 487 vs. 560 + 253 vs. 618 + 217 fmol/mg protein). Simple correlation analyses showed that, within AN but not within controls, paroxetine binding was inversely related to dieting preoccupations, affective instability, anxiousness, compulsivity, restricted expression and social avoidance but independent of age, body mass index, depression, and other eating symptoms. Findings suggest that reduced peripheral serotonin transporter density in AN relates to increased dieting preoccupations, affective instability and anxiousness–fearfulness.

Factors related to severity of vomiting behaviors in bulimia nervosa

Assessments of the severity of vomiting (weekly frequency), depressive and eating-related psychopathology, anger level and management, and personality dimensions were used to characterize patients with bulimia nervosa binge purging type (BN-BP). The sample comprised 130 outpatients with BN and 130 control women. The Eating Disorder Inventory-2 (EDI-2), the State-Trait Anger Expression Inventory, the Beck Depression Inventory, and the Temperament and Character Inventory (TCI) were administered to all patients. The Self-Directedness dimension of the TCI and the Bulimia subscale of the EDI-2 were the strongest predictors of the severity of bulimic behavior; anger levels and anger expression were not so strongly related to illness severity. A more severe form of bulimic symptomatology probably has substrata in specific character deficits (low Self-Directedness on the TCI) and particular psychopathological features (high bulimia on the EDI-2). Patients with a high frequency of vomiting need specific therapeutic interventions to enhance the character dimension of Self-Directedness.

The impact of physical and sexual abuse on body image in eating disorders

Objective The role of childhood sexual abuse as a risk factor for the development of eating disorders has gained considerable attention in the literature in the last few years, especially its role in bulimia nervosa. Although physical abuse was also frequently explored in the history of patients with eating disorders, its role was unclear in the aetiopathogenesis of these disorders. The goal of our study was to test the hypothesis, based on our clinical experience, that physical abuse is more frequent in eating disorders than thought previously and that the patient's distortion in body image is more severe in these cases. Method A standardized interview method was used to elicit details of physical and sexual abuse in a group of 63 patients with eating disorders. The frequency of laxative use and the severity of body image distortion was also examined with the Body Attitude Test. These clinical data were analysed on the whole sample and also on the subgroups of eating disorders. Results We found significantly more severe body image distortions in those patients who had been physically abused (p < 0.05) and there were significantly more severe body image distortions in those patients who had a history of laxative abuse (p < 0.001). Sexual abuse occured in 29%, physical abuse in 57% and laxative abuse in 46% within the whole sample of examined eating disorder patients. Physical abuse and laxative abuse were the most frequent in the binge eating/purging type of anorexia nervosa (92% and 69%). Also, these patients had the worse rates on sexual abuse and body image distortion items. According to our results, the presence of sexual abuse was not associated with more severe body image distortion in eating disorder patients. Conclusions Childhood physical abuse seems to be a more important factor in the development of body image distortion than had been thought before; its importance in this aspect may be greater than sexual abuse. Physical abuse, laxative abuse and the binge–purge subtype in anorexia nervosa are a considerable risk factor for the severity of the distortion in body image and their presence makes the prognosis of the eating disorder worse. Further studies of the nature of these relationships are warranted. Copyright © 2005 John Wiley & Sons, Ltd and Eating Disorders Association.

Implications of compulsive and impulsive traits for serotonin status in women with bulimia nervosa

Studies of bulimia nervosa (BN) often report decreased brain serotonin (5-hydroxytryptamine: 5-HT) activity. Across populations, impulsivity has been linked to reduced 5-HT activity, but compulsivity has been associated (at least inconsistently) with an increase. We therefore became interested in the association between behavioral-trait variations and 5-HT status in BN. In 56 bulimic and 29 non-bulimic women, we measured eating symptoms, personality traits, platelet paroxetine binding, and neuroendocrine responses following oral meta-chlorophenylpiperazine (m-CPP). Relative to normal eaters, bulimic women showed reduced density ( B max) of platelet paroxetine-binding sites, blunted prolactin (PRL) responses following m-CPP, and (as a trend) lower basal PRL levels. However, after effects of binge–purge frequencies, body mass, and other extraneous factors were controlled, PRL levels at baseline and other moments in the serial sampling varied systematically with presence of impulsive and compulsive traits. PRL was generally low in BN, but ‘high-compulsive’/‘low-impulsive’ traits were associated with higher (normal-range) PRL values. Comparable trait-related variations were not observed on paroxetine-binding indices. Our findings suggest that 5-HT status in BN may correspond to impulsive or compulsive traits, and they encourage multidimensional modeling of the pathophysiological role of 5-HT in BN.

Combined family trio and case-control analysis of the COMT Val158Met polymorphism in European patients with anorexia nervosa.

The high activity Val158 (H) allele of the dopamine-metabolizing enzyme catechol-O-methyltransferase (COMT) was associated with anorexia nervosa (AN) in a recent family trio-based study of patients from Israel. In an attempt to replicate this finding, we performed a combined family trio and case-control study in an European population from seven centers in six different countries (Austria, Germany, Great Britain, Italy [Milan], Italy [Florence], Slovenia, and Spain), together contributing a total of 372 family trios, 684 controls and 266 cases. TDT analyses of high (H) and low (L) alleles in family trios showed that H allele and L allele were each transmitted 101 times (chi(2) = 0, ns). Allele-wise case-control analysis using separate samples simply combined from the centers was also not significant, with the frequencies of the H allele 50% in cases and same in controls. Stratified analysis of data from all centers gave an odds ratio of 0.98 (Cornfield 95% confidence limits 0.78-1.24). Analysis by genotype was likewise not significant (overall chi(2) = 0.42). Because we were not able to support the primary hypothesis that Val158Met is a risk factor for AN, we did not perform secondary analysis of minimum body mass index (mBMI), age at onset or illness subtype (restricting or binge purging anorexia). Overall we found no support for the hypothesis that the Val158 allele of COMT gene is associated with AN in our combined European sample.

Prospective predictors of the onset of anorexic and bulimic syndromes.

This study investigated prospective predictors of lifetime history diagnoses of partial- and full-syndrome anorexia nervosa and bulimia nervosa (referred to as anorexic syndrome and bulimic syndrome.) Participants were 157 females who were studied initially in the 7th-10th grades (ages 12-16) and followed-up 2 and 8 years later in middle adolescence (ages 14-18) and young adulthood (ages 20-24), respectively. A telephone interview to determine lifetime history of anorexic and bulimic syndromes was conducted in young adulthood. In multivariate analyses controlling for initial eating symptoms, initial perfectionism and low body weight predicted young adult onset of anorexic syndrome, and initial negative emotion predicted young adult onset of bulimic syndrome. Our findings suggest that adolescent girls who are initially thin and also adhere to perfectionistic standards may be at risk for developing anorexic syndrome. For bulimia, negative affect may contribute to the development of the binge-purge cycle.

Gender-Related Self-Discrepancies and Bulimic Eating Behavior

The purpose of this study was to explore a hypothetical link between the development of bulimic eating behavior and the suppression of masculine traits in adolescence. Discrepancies between the actual and the ideal self were examined as precursors of negative self-evaluation and binge–purge behavior. Using the Bem Sex-Role Inventory (Bem, 1974), 821 German students between the ages of 13 and 20 were questioned anonymously. Data were analyzed with structural equation modeling. For girls in contrast to boys, the discrepancy between how much adolescents believed that they possess masculine traits (actual self) and how much they would like to (ideal self) was significantly greater at older ages. For both sexes, gender-related self-discrepancies were related to bulimic symptoms indirectly, via self-esteem and dieting.

Meta-analysis of CBT for Bulimia Nervosa: Investigating the Effects Using DSM-III-R and DSM-IV Criteria

This meta-analysis reports the effects of cognitive-behavioural treatment (CBT) on bulimia nervosa as defined by the DSM-III-R or DSM-IV criteria. In a previous meta-analysis, 26 studies were included using less strict diagnostic criteria for inclusion. The present meta-analysis only included randomized controlled studies fulfilling the DSM-III-R or DSM-IV criteria. Computer searches in MedLine, PsychLIT and references cited herein resulted in a large number articles, of which only seven fulfilled the criteria for inclusion. Effect sizes for binge eating and purging frequency were estimated using both between-group (treatment vs control) and within-group (pre- vs post-treatment) comparisons. The combined within-group effect size for binge eating was r = 0.55 ( d = 1.32) and for purging r = 0.61 ( d = 1.54). The corresponding combined effects for the between-group comparisons were r = 0.23 ( d = 0.47) and r = 0.28 ( d = 0.58), respectively. The combined probabilities for frequency of purging in between- and within-group comparisons were p = 0.00001 and p = 0.00000001, respectively. Although the number of studies included in the meta-analysis was limited, the obtained results are in line with the findings of the previous meta-analysis, and support the efficacy of CBT for the treatment of bulimia nervosa. This suggestion is also supported by the fact that in all the studies except one, comparison groups had received other active treatments.

Features of eating disorders in patients with irritable bowel syndrome

The relationship between characteristics of irritable bowel syndrome (IBS) and eating disorders (ED) was investigated in a clinical sample of 43 female and 17 male IBS patients who completed the Eating Disorder Inventory (EDI). A diagnosis of IBS was generally unrelated to the Body Dissatisfaction, Perfectionism, and Ineffectiveness subscales of the EDI, but symptom severity was correlated with Perfectionism and Ineffectiveness. Severe bouts of vomiting were significantly associated with desires for lower body weight and reported binge–purge behaviors and cognitions measured by the Bulimia subscale of the EDI. Results suggest the need for a more comprehensive understanding of both types of illness as well as a possible framework for future empirical work.

Bulimia nervosa and depression: a theoretical and clinical appraisal in light of the binge-purge cycle.

This review seeks to familiarize clinicians with several major theoretical perspectives on the relationship between bulimia nervosa and depression. It begins by clarifying the affective changes which occur within the binge-purge cycle. Six hypotheses relating negative affect to bulimia nervosa are then reviewed in light of these changes, with their strengths, weaknesses and clinical implications clearly outlined. The author concludes that, although none of these perspectives has received universal support, recent hypotheses which focus upon specific portions of the binge-purge cycle are best suited to integration. These include the restraint, escape and hopelessness hypotheses. An integrative model is proposed to account for data across the binge-purge cycle, to assist in understanding the maintenance of bulimia nervosa, and to guide clinical intervention.

Cognitive treatments for eating disorders.

Cognitive-behavioral therapy (CBT) is applicable to all eating disorders but has been most intensively studied in the treatment of bulimia nervosa (BN). CBT is designed to alter abnormal attitudes about body shape and weight, replace dysfunctional dieting with normal eating habits, and develop coping skills for resisting binge eating and purging. CBT is effective in reducing all core features of BN and shows good maintenance of therapeutic improvement. Although superior to therapy with antidepressant drugs, CBT has not been shown to be consistently superior to alternative psychological treatments. Different hypotheses about CBT's mechanisms of action are discussed.

The Bulimia Test—Revised: A psychometric investigation.

The Bulimia Test-Revised (BULIT-R; Thelen, Farmer, Wonderlich, & Smith, 1991) is a 28-item questionnaire that shows promise as a sound and valid global self-report measure of the multidimensional bulimia nervosa construct. This study estimated the reliability and construct validity of the BULIT-R. Specifically, the study examined the correspondence between BULIT-R scores and the self-monitored frequency of the bulimic symptoms of binge eating and purging among 39 college-aged women. Results support the internal consistency, temporal stability, and construct validity of the BULIT-R

Mood changes and affective disorder in the bulimic binge—Purge cycle

Mood changes over the bulimic binge–purge cycle were studied in retrospective questionnaire reports of patients, 16 with and 34 without concurrent affective disorder. Moods clearly differed over phases. Mood reports depicted the period between the binge and purge as most unpleasant, with low energy/excitement and security/relief and high panic/helplessness and guilt/disgust/anger. Feelings after the purge were relatively calm and pleasurable, with low panic/helplessness and excitement/energy and high security/relief. Patients with affective disorder did not differ from those without affective disorder in their mood changes during the cycle.

The bulimia workshop: a unique integration of group treatment approaches.

The time constraints of weekly group therapy and the slow evolution of group cohesion attenuate the direct confrontation that is essential with bulimic patients. Consequently, a three-phase, multidimensional group program was devised to accelerate the treatment process. Treatment begins with an intensive weekend workshop during which members formulate contracts for interrupting the binge–purge cycle and changing symptomatic behavior. During a follow-up session problems in fulfilling the contracts are dealt with and successes are reinforced, in the final phase, group members convene without their therapists to provide peer support, reevaluate contracts, and share feelings regarding treatment progress. The unique implications for treatment process and therapist interventions prompted by this new format are discussed, and preliminary research findings are highlighted.