Restrictive Anorexia Research Articles

The significance of body size estimation in eating disorders: its relationship with clinical and psychological variables.

To assess the relationship between body size estimation on the one hand and clinical and psychological variables on the other. Body size estimation was tested with the video distortion method on a life-size screen in normal women (n = 45) and compared to a total of 189 female eating disorder patients (100 with restricting anorexia nervosa, 41 with binging/purging anorexia nervosa, 48 with bulimia nervosa). The subjects' cognitive responses (what they think they really look like), affective responses (what they feel they look like), and optative responses (what they want to look like) were correlated with clinical parameters (including body composition) and with the scores on a series of self-report questionnaires assessing general psychological well-being and body experience. No significant relationship was found between the body size estimations and the clinical variables. The cognitive and affective responses showed a moderate relationship with self-reported body attitude. Body dissatisfaction was negatively correlated with the optative response (desired body size). This study contributes to the construct validity of the video distortion method. Body size estimation includes more than just a perceptual task. Hence, the narrow notion of body image should be replaced by the more complex construct of "body experience," the multidimensionality of which should be addressed in both research and treatment of eating-disordered patients.

A controlled family study of anorexia nervosa and bulimia nervosa: psychiatric disorders in first-degree relatives and effects of proband comorbidity.

We used contemporary family-epidemiological methods to examine patterns of comorbidity and familial aggregation of psychiatric disorders for anorexia and bulimia nervosa. Direct interviews and blind best-estimate diagnostic procedures were used with diagnostically "pure" groups of probands with eating disorders and a matched control group. Lifetime prevalence rates of eating disorders, mood disorders, substance use disorders, anxiety disorders, and selected personality disorders were determined in female probands with restricting anorexia nervosa (n=26) or bulimia nervosa (n=47), control women (n=44), and first-degree biological relatives (n=460). Relatives of anorexic and bulimic probands had increased risk of clinically subthreshold forms of an eating disorder, major depressive disorder, and obsessive-compulsive disorder. Familial aggregation of major depressive disorder and obsessive-compulsive disorder was independent of that of anorexia nervosa and bulimia nervosa. These relatives also had increased risk of other anxiety disorders, but the mode of familial transmission was not clear-cut. The risk of substance dependence was elevated among relatives of bulimic probands compared with relatives of anorexic probands, and familial aggregation was independent of that of bulimia nervosa. The risk of obsessive-compulsive personality disorder was elevated only among relatives of anorexic probands, and there was evidence that these 2 disorders may have shared familial risk factors. There may be a common familial vulnerability for anorexia nervosa and bulimia nervosa. Major depressive disorder, obsessive-compulsive disorder, and substance dependence are not likely to share a common cause with eating disorders. However, obsessional personality traits may be a specific familial risk factor for anorexia nervosa.

Personality disorders in patients with eating disorders in Japan.

We assessed the prevalence of personality disorders (PD) using the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) in 36 patients with restricting anorexia nervosa, 30 patients with anorexia nervosa and bulimia nervosa, and 42 patients with bulimia nervosa. Of the 108 patients, 51% met the criteria for at least one PD. The patients with PD had more severe clinical features in terms of bulimic behaviors, concurrent depressive, anxious, and obsessive-compulsive symptoms, and psychopathology related to eating disorders compared to the patients without any PD. The patients with PD, especially borderline PD, also had more severe global functioning and greater numbers of suicidal attempts and hospital admissions. We compare these results with those reported in the Western world and discuss them cross-culturally.

Personality disorders in patients with eating disorders in Japan

We assessed the prevalence of personality disorders (PD) using the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) in 36 patients with restricting anorexia nervosa, 30 patients with anorexia nervosa and bulimia nervosa, and 42 patients with bulimia nervosa. Of the 108 patients, 51% met the criteria for at least one PD. The patients with PD had more severe clinical features in terms of bulimic behaviors, concurrent depressive, anxious, and obsessive-compulsive symptoms, and psychopathology related to eating disorders compared to the patients without any PD. The patients with PD, especially borderline PD, also had more severe global functioning and greater numbers of suicidal attempts and hospital admissions. We compare these results with those reported in the Western world and discuss them cross-culturally. © 1998 John Wiley & Sons, Inc. Int J Eat Disord 23: 399–408, 1998.

Hypnotic susceptibility, or F‐bias: its relevance to eating disorders

AbstractHypnosis research and theory has recently paid increasing attention to hypnotizability as a trait in its own right and to a convergence with ideas in neuropsychology. Hypnotizability, or F‐bias, may be broadly characterized as involving focused attention, flexibility in switching cognitive styles and the activity of frontal cortical systems. F‐bias/hypnotizability correlates with a number of activities other than hypnotic performance, one of which is disordered eating behaviour. Within the clinical literature the general finding has been that restricting anorexics are of normal or slightly above normal hypnotizability whereas bulimics are very significantly above normal hypnotizability and show increased dissociative tendencies. In normal weight non‐clinical populations also there is also a positive correlation between hypnotizability, dissociative tendencies and attitudes to food intake. A recent study looked at both dissociation and hypnotizability in relation to disordered eating, as measured by an eating questionnaire, in a normal weight female undergraduate population. The data confirmed that those with bulimic tendencies scored higher on both hypnotizability and dissociation. The results also showed that hypnotizability was specifically related to a factor of dietary restraint, whereas dissociation was related to a factor of impulsive eating. The latter may account for the binge components of disordered eating. In contrast to earlier views, which tended to equate hypnotizability and dissociative tendencies, these data suggest that they are independent factors which influence different aspects of eating behaviour. Other work is described, which indicates that restrained eaters are more responsive than non‐restrained eaters to suggestions of increased body size, which may account in part at least for the distortions of body image seen in clinical eating disorders. The ways in which both hypnotizability and dissociative tendencies might operate as independent moderators in a sociocultural model of the development of anorexia and bulimia nervosa are discussed. Copyright © 1998 British Society of Experimental and Clinical Hypnosis

Body size estimation in anorexia nervosa patients: the significance of overestimation

Using the video distortion method on a life-size screen, we have studied body size estimation in 100 female restricting anorexia nervosa patients. About half of the patients were accurate in estimating their own body dimensions and only 20% clearly showed overestimation. We then tested whether differences in accuracy of estimation were related to scores on the following questionnaires: Eating Disorder Inventory; Body Attitude Test; and Symptom Checklist (SCL-90). Overestimators reported a more negative body attitude and a more “neurotic profile” on the SCL-90. These differences might have both prognostic and therapeutic implications.

A comparison of subgroups of inpatients with anorexia nervosa

Objective Classification of subgroups of people with anorexia nervosa has been in flux. It has not been clear whether anorexics who only purge should be grouped with pure restricters or with people who both binge and purge. Methods: We compared 27 restricting-type anorexics (RAN), 26 bulimic anorexics (BAN), and 34 restricting anorexics with purging behaviors (RAN-P). All subjects were underweight and recently admitted to a hospital. We excluded subjects who had not had a diagnosis of anorexia nervosa for at least 1 year duration. Results: The three groups of subjects had similar scores for Depression and Anxiety on the Beck Depression Inventory, the Spielberger State and Trait Anxiety Inventory, and on the EDI subscales aside from higher scores for BAN subjects on the Bulimia subscale. Discussion: These three subgroups of anorexia nervosa have similar degrees of dysphoric moods and core eating disorder symptoms when underweight and malnourished. © 1997 by John Wiley & Sons, Inc. Int J Eat Disord 22:309–314, 1997.

Subtyping Eating Disorders: Is It Justified?

DSM-IV subtypes anorexia nervosa by the presence or absence of bulimic symptoms. Assessing whether bulimic symptoms are related to the probability of recovery can provide justification for subtyping of anorexia. Two hundred twenty-five treatment-seeking women with anorexia and/or bulimia nervosa were interviewed every 3 months for up to 4 years. Survival methods were used for analyses. Less than half of the entire cohort recovered; however, the great majority of the women became less symptomatic over time. Contrary to findings from previous studies, bulimic anorexics had a higher rate of recovery than restricting anorexics. Differences in course provide some support for the subtyping of anorexia nervosa. Additional prospective studies are needed before subtyping can be warranted.

Food preferences and desire to eat in anorexia and bulimia nervosa

To determine whether eating disordered patients and controls differ in visual analog scale (VAS) ratings of liking and desire to eat various foods and whether ratings differ according to caloric or macronutrient content of the foods. Fifty-five female inpatients with eating disorders and 15 controls rated their liking of and desire to eat 50 common foods at admission and discharge using 100-mm VAS. All patient groups rated their desire to eat high-calorie foods significantly lower than their desire to eat low-calorie foods whereas controls rated their desire to eat high- and low-calorie foods equally. Patients also differed from controls more in ratings of desire to eat than in liking when foods were classified according to macronutrient content. In restricting anorexics (N = 25), ratings of liking and desire to eat for high-fat/low-carbohydrate (CHO) and high-fat/high-CHO foods were not significantly correlated at admission. Disparity in correlations between restrictors, bulimics (N = 18), and controls was attenuated with treatment while anorexics with bulimic features (N = 12) became less like controls from admission to discharge. Differences in the way patients and controls perceive foods should be borne in mind during the treatment process. Furthermore, since patients had not completely normalized by discharge, treatment strategies should emphasize acceptance of foods varying in macronutrient and caloric content, as intake of a varied diet is of key importance in regaining and maintaining good health.

1801 Song recognition of the zebra finch

Les automutilations recouvrent plusieurs types de conduites, de la simple excoriation cutanée à l’autocastration. Il est actuellement difficile d’obtenir une définition consensuelle de ce type de troubles. Pour certains auteurs, les blessures auto-infligées sont un symptôme pathognomonique de la personnalité « borderline » ; pour d’autres, il s’agit au contraire d’une entité diagnostique à part entière, amenant ainsi à définir de nouveaux syndromes. Ces comportements d’automutilation sont particulièrement fréquents chez les adolescents, avec une prépondérance féminine et chez les patients présentant une pathologie psychiatrique. La plupart des sujets utilisent plusieurs méthodes pour s’automutiler et privilégient différentes localisations pour les automutilations, celles-ci sont souvent associées à des comorbidités psychiatriques. Cette étude décrit une cohorte de 30 patients hospitalisés s’automutilant et compare les données recueillies (sociodémographiques, antécédents, comorbidités et type d’automutilation) à celles de la littérature. Le groupe se compose majoritairement de filles et l’âge moyen est de 18 ans. Trente pour cent des patients disent avoir subi des maltraitances durant l’enfance, 60 % sont suivis sur le plan psychiatrique et 73 % ont un antécédent de tentative d’autolyse. Tous les patients se sont infligés des blessures à au moins deux reprises et plusieurs moyens sont associés dans la plupart des cas (incision des avant-bras le plus souvent). Les conduites addictives telles que l’abus de substance (tabac 46,7 % ; alcool 23,3 % ; toxique 16,7 %) et les troubles des conduites alimentaires (33,3 %) sont fréquemment associés aux automutilations. Enfin, trois diagnostics sont principalement retrouvés dans notre cohorte (syndrome dépressif 36,7 % ; trouble de personnalité 20 % ; trouble psychotique 10 % ; association d’un syndrome dépressif et d’un trouble de personnalité 33,3 %).Deliberate self-injury is defined as the intentional, direct injuring of body tissue without suicidal intent. There are different types of deliberate self-mutilating behaviour: self cutting, phlebotomy, bites, burns, or ulcerations. Sometimes, especially among psychotic inpatients, eye, tongue, ear or genital self-mutilations have been reported. In fact, self-mutilation behaviour raises nosological and psychopathological questions. A consensus on a precise definition is still pending. Many authors consider self-mutilating behaviour as a distinct clinical syndrome, whereas others hold it to be a specific symptom of borderline personality disorder. Self-mutilating behaviour has been observed in 10 to 15% of healthy children, especially between the age of 9 and 18 months. These self mutilations are considered as pathological after the age of 3. Such behaviour is common among adolescents, with a higher proportion of females, and among psychiatric inpatients. Patients use different locations and methods for self-mutilation. Deliberate self harm syndrome is often associated with addictive behaviour, suicide attempt, and personality disorder.We report on an observational study including 30 inpatients and we compared the data with the existing literature. As a matter of fact, until now, most of the papers deal with case reports or with very specific patterns of self-mutilation (eye, tongue or genital self-mutilations). Otherwise, papers report the relationships between self-mutilation and somatic or personality disorders (Lesh Nyhan syndrome, borderline personality disorder, dermatitis artefacta, self-mutilation in children following brachial plexus related to birth injury, mental retardation...). Our study included all self harmed patients who had been admitted to our psychiatric hospital (whatever the location and type of self-mutilation). Patients suffering from brain injury or mental retardation were excluded.In our sample, there was a higher percentage of women (29 women and 1 man) and the mean age was 18 (12 to 37). More than half of the patients were aged under 18. Single parent families were reported in 30% of cases. Thirty percent of patients had been physically or sexually abused during childhood. Sixty percent had a comorbid psychiatric disorder, 63% had been hospitalised previously (half of them twice or more). Seventy-three percent of patients had previously attempted suicide (notably deliberate self-poisoning and cutting) that was not considered as self-mutilating behaviour by the patients themselves. Each patient had self harmed themselves at least twice and most often different methods and locations were used (deliberate self harm of forearms 90%, thighs 26.7%, legs 16.7%, chest 10%, belly 10%, hands 6.9%, face 6.9%, arms 6.7%, and feet 3.3%). Addictive disorders, such as substance abuse (tobacco 46.7%; alcohol 23.3%; illicit drugs 16.7% mostly cannabis or cocaine) and eating disorders (33.3% and among them 50% of cases were restrictive anorexia nervosa) were often associated with a deliberate self harm syndrome. Three psychiatric diagnoses were often observed in our cohort: depressive disorder 36.7%; personality disorder 20%; psychosis 10% and depressive disorder associated with personality disorder 33.3%. In our sample, psychotic patients differed on several clinical aspects: the atypical location (abdomen, nails) and method (needles) of self-mutilating behaviour. None of them had been abused during childhood and none was suffering from addictive disorders.

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.

Anorexia Nervosa and Bulimia Nervosa in Adolescence: Effects of Age and Menstrual Status on Psychological Variables

To compare, in adolescents and adults with anorexia nervosa and bulimia nervosa, eating disorder symptomatology and comorbid affective and anxiety states. Two hundred fifty consecutive, female inpatients on an eating disorders unit were studied. They were given the Beck Depression Inventory; the Depression, Obsessive-Compulsive, Anxiety, and Phobic Anxiety scales from the Symptom Checklist 90; and the Eating Disorder Inventory. Patients were divided into categories based on age, diagnosis, and menstrual status. Onset of anorexia nervosa before age 14 and primary amenorrhea were associated with the greatest maturity fears during acute illness. For patients with restricting anorexia, adolescents aged 17 through 19 years had the highest drive for thinness compared to adolescents aged 13 through 16 years and adults. The lowest levels of depression and anxiety were seen in patients younger than age 14 with restricting anorexia. Overall, few psychological differences between adults and adolescents with eating disorders were found, with the exceptions of the youngest restricting anorectic patients at the time of treatment and both restricting and bulimic-anorectic patients who had a very early onset of their illness. Younger patients with acute anorexia nervosa may not require pharmacotherapy for anxiety and depression and may benefit from a focus on maturity fears in psychotherapy.

Puberty, sexual milestones and abuse: how are they related in eating disorder patients?

In order to assess the relationship pubertal development, sexual milestones and childhood sexual abuse in women with eating disorders, 44 patients with restricting anorexia nervosa (RAN), 26 with bulimic anorexia nervosa (BAN), 29 with bulimia nervosa and also with a history of anorexia nervosa (BN/HistAN), and 69 with bulimia nervosa but without a history of anorexia nervosa (BN) completed questionnaires on pubertal and sexual development and unpleasant sexual experiences. Forty-four female college students complete the sexual development questionnaire only. Different eating disorder groups were found to be similar in terms of their pubertal development. All eating disorder groups showed delays in aspects of their psychosexual development (age at first kiss, masturbation, genital fondling and first sexual intercourse) compared with the control group, although to a different degree. The RAN group was delayed on almost all sexual milestones whereas the other groups were delayed on only some. On some variables, most noticeably on first sexual intercourse, restricters also were more delayed than the other eating disorder groups. Similarly, the median number of sexual partners differed significantly between groups (RAN = 1, BAN = 2, BN/HistAN = 4, BN = 4, controls = 5, P < 0.0001). Eating disorder patients, in particular RAN patients, were less positive about sexual relationships than controls, but did not differ from controls in attitudes to masturbation, marriage, children or pregnancy. Of the eating disorder patients 22-31% had been sexually abused during childhood. A history of abuse affected attitudes to masturbation, but did not appear to affect sexual development.

Hypokalemia in outpatients with eating disorders.

The literature on the prevalence and importance of hypokalemia in persons with eating disorders in contradictory and confusing. The authors investigated the frequency of hypokalemia and its relationship to symptoms in a group of outpatients with eating disorders. Diagnostic evaluations and electrolyte studies were performed for 945 outpatients meeting the DSM-III-R criteria for eating disorders at the time of their intake evaluations at a suburban clinic for eating disorders. Clinically significant hypokalemia was comparatively rare. A total of 43 subjects (4.6%) were hypokalemic; of these, seven (0.7% of all subjects) were borderline hypokalemic (serum potassium = 3.4 mmol/liter). The hypokalemic subjects had a significantly lower mean weight and body mass index at entry than the normokalemic subjects. Significantly more of the hypokalemic subjects purged by abusing laxatives, either alone or with vomiting. The patients with restricting (nonpurging) anorexia nervosa, even those whose weights were very low, were generally normokalemic. The low frequency of hypokalemia in this group of eating disordered outpatients suggests that routine electrolyte determination is a poor screening tool for occult or denied bulimia. Hypokalemia occurred almost invariably in lower-weight bulimic (or anorectic/bulimic) patients who were vomiting and/or abusing laxatives. Indeed, the study suggests that hypokalemia in a patient with an eating disorder is virtually certain evidence that the patient is purging at least daily. In addition, it appears that a patient with purely restricting anorexia nervosa is not at risk for hypokalemia even if his or her weight is very low.

Personality variables and disorders in anorexia nervosa and bulimia nervosa.

All dominant models of the eating disorders implicate personality variables in the emergence of weight concerns and the development of specific symptoms such as bingeing and purging. Standardized measures of personality traits and disorders generally confirm clinical descriptions of restricting anorexics as constricted, conforming, and obsessional individuals. A less consistent picture suggesting affective instability and impulsivity has emerged from the assessment of subjects with bulimia nervosa. Considerable heterogeneity exists within eating disorder subtypes, however, and a number of special problems complicate the interpretation of personality data in this population. These include young age at onset, the influence of state variables such as depression and starvation sequelae, denial and distortion in self-report, the instability of subtype diagnoses, and the persistence of residual problems following symptom control.

Personality variables and disorders in anorexia nervosa and bulimia nervosa.

All dominant models of the eating disorders implicate personality variables in the emergence of weight concerns and the development of specific symptoms such as bingeing and purging. Standardized measures of personality traits and disorders generally confirm clinical descriptions of restricting anorexics as constricted, conforming, and obsessional individuals. A less consistent picture suggesting affective instability and impulsivity has emerged from the assessment of subjects with bulimia nervosa. Considerable heterogeneity exists within eating disorder subtypes, however, and a number of special problems complicate the interpretation of personality data in this population. These include young age at onset, the influence of state variables such as depression and starvation sequelae, denial and distortion in self-report, the instability of subtype diagnoses, and the persistence of residual problems following symptom control.

Childhood adversity and adult defence style in eating disorder patients--a controlled study.

The aims of the study were (1) to compare the defence style of patients with anorexia nervosa with that of patients with bulimia nervosa and of female controls; (2) to establish whether a link exists between childhood adversity and adult defence style in eating disorder patients. Twenty-six patients with restricting anorexia nervosa (RAN), 61 patients with bulimia nervosa (BN), 37 patients with bulimic anorexia nervosa or bulimia nervosa with a history of anorexia nervosa (BAN/BN-HistAN) and 88 female controls were given the short Defense Style questionnaire (Andrews, Pollock & Stewart, 1989). Eating disorder patients were asked about their childhood care using a semi-structured interview (Harris, Brown & Bifulco, 1986). Bulimia nervosa patients had a significantly less mature defence style than the other groups and like the BAN/BN-HistAN group more immature defences than the control group. In the RAN group no childhood predictors of adult defence style were found, whereas in bulimia nervosa, excessive parental control during childhood was a negative predictor of mature defences and physical abuse a positive predictor of immature defence style. These results provide some evidence that childhood adversity may constitute a vulnerability factor for the later development of bulimia nervosa, mediated by personality development.

Anorexia nervosa: Empirical basis for the restricting and bulimic subtypes

The future revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) will describe diagnostic criteria for two anorexia nervosa subgroups: a binge eating or bulimic subtype, and a severe food restriction subtype. The present literature review will help orient nutrition and dietetic students, educators and researchers to the empirical bases for these subtypes. Available research on these two subtypes is equivocal. However, some important trends have emerged. Compared with restricting anorexics, bulimic anorexics are described by others as being significantly more unhappy during childhood and displaying a greater range of impulsive behaviors. In addition, bulimic anorexics have a higher lifetime prevalence of formal mood disorders, tend to use more alcohol and drugs, and tend to meet the criteria for DSM III-R Cluster B Personality disorders rather than those for Cluster C. Also, the bulimic subtype tends to have a more chaotic family environment. Finally, more patients of the bulimic subtype seem to show subaverage bone density, suggesting a higher risk for chronic osteoporosis. The present review discusses the significant research and treatment implications of the differences between these anorexic subtypes.

Setting the scene for eating disorders: childhood care, classification and course of illness.

The aim of this study was to determine whether the childhood experiences of patients with anorexia nervosa and bulimia nervosa differ and affect the course of the illness. A semistructured interview developed by Harris et al. (1986) was used to assess the childhood family environment of 64 patients with restricting anorexia nervosa (RAN), 23 patients with bulimic anorexia nervosa (BAN), 37 bulimic patients with a history of anorexia nervosa (BN/HistAN) and 79 patients with normal weight bulimia nervosa (BN). There were no significant differences between groups in terms of parental mental disorder, low parental control or childhood sexual abuse. BN patients had had significantly more family arrangements and had experienced more parental indifference, excessive parental control, physical abuse, and violence against other family members than RAN patients with the BAN and BN/HistAN group being intermediate. There was a trend for BN-patients to have had more intra-familial discord than the other groups. Different aspects of adversity tended to cluster in the same patients and 65% of the bulimic group had experienced two or more types of childhood adversity. These results suggest that childhood experiences contribute to the form of eating disorder which later develops.

Association of sexual abuse and borderline personality disorder in eating disordered women.

It has been shown that sexual abuse is associated with the eating disorders, particularly those with a bulimic component. Existing research suggests that borderline personality disorder (or the cluster of behaviors behind this diagnosis) may be a mediating factor in that link. However, there is no evidence of specific patterns of association between the three phenomena. The present report studies these links in a case series of 115 eating-disordered women. It is shown that the links between and reported sexual abuse and borderline personality disorder vary according to the nature of the eating disorder. In particular, they were associated in anorexia of the bulimic subtype, but not in bulimia nervosa or in restrictive anorexia. The possible therapeutic implications of these findings are discussed.