Anxiety and Disordered Eating

Anorexia Nervosa

Eating Disorders: What Are the Risks?

Many believe that the current application of modern logistics solutions in general and centralisation of distribution systems in particular is damaging from an environmental perspective. The reason for this claim is that when a distribution system is centralised, products need to be shipped over greater distances. This causes an increase in transport work, which in turn is believed to cause an increase in emissions. Further, the decision to centralise distribution can be characterised as a structural decision and earlier research has helped illustrate how such decisions have greater impact on the overall performance of a distribution system than decisions taken at subsequent levels (tactical and operative). The reason for this is that structural decisions help create new opportunities to make other logistical decisions that are beneficial for the performance of a distribution system, as measured in terms of costs and service. It is also acknowledged that there is a lack of research illustrating the actual environmental effects of centralisation. This area is the theme of this thesis and the overall purpose is to describe and analyse how centralisation of a distribution system can affect the environment. This purpose has been divided into two research questions, where the first one reads: - How does physical centralisation of a distribution system influence the environment? This question aims at investigating what effect centralisation has on the amount of emissions that are caused by transport in a distribution system. One of the main advantages with a centralised distribution system is that emergency deliveries are expected to decrease. This type of transport is often performed by airfreight, which is a mode of transport that is regarded to cause the largest amount of environmental stress among the four most commonly used transport modes. The argument that is made is that even though centralisation causes an increase in transport work, this must not necessarily mean that emissions increase. As indicated above, earlier studies on structural changes in distribution systems have shown that this type of decision creates new opportunities to make other decisions that are beneficial for the performance of a distribution system, albeit in terms of costs and service. The aim of the second research question is consequently to study this issue, but from an environmental perspective. This question therefore reads: - How do structural decisions in logistics create new opportunities to improve on the environmental performance of a distribution system? The results of the study show that it is not sufficient to only consider transport work and emergency deliveries when the environmental effect of a centralisation is to be evaluated. It has also been concluded that centralisation creates an opportunity to make improvements within the distribution system that can prove beneficial from an environmental perspective. In summary, three characteristics besides transport work and emergency deliveries were identified as being of importance when considering the environmental effects of a centralisation. These included centralised flow, modal change, and bargaining power. This model (see full pdf) does not aim to include all characteristics that can be relevant in an environmental evaluation of a centralisation, but rather those that have been found significant in this study. However, the model helps illustrate that there are many aspects that need to be considered in such an evaluation and that depending on the characteristics of the distribution system at hand the results can vary quite extensively.

Imaging of Eating Disorders: Multiple Techniques to Demonstrate the Dynamic Brain

It has been suggested that childhood obsessive-compulsive disorder (OCD) may be a risk factor for the development of an eating disorder (ED) later in life, but prospective studies are lacking. We aimed to determine the prevalence of ED at follow-up and clinical predictors in a longitudinal clinical sample of adolescents/young adults diagnosed with OCD in childhood. All contactable (n=231) young people with OCD assessed over 9 years at a national and specialist paediatric OCD clinic were included in this study. At follow-up, 126 (57%) young people and parents completed the ED section of the Developmental and Well-being Assessment. Predictors for ED were investigated using logistic regression. In total, 16 participants (12.7%) had a diagnosis of ED at follow-up. Having an ED was associated with female gender and persistent OCD at follow-up. There was a trend for family history of ED being predictive of ED diagnosis. Five (30%) of those who developed an ED at follow-up had ED symptoms or food-related obsessions/compulsions at baseline. A difference in predictors for an ED versus other anxiety disorders at follow-up was identified. This study provides initial evidence that baseline clinical predictors such as female gender and family history of ED might be specific to the later development of ED in the context of childhood OCD. Clinicians should be alert to ED subthreshold symptoms in young girls presenting with OCD. Future longitudinal studies are needed to clarify the relationship between childhood OCD and later ED.

IntroductionOrthorexia Nervosa (ON) is characterized by an obsessive focus on healthy eating, leading to extreme restrictions and negative impacts on mental and social health. ON shares traits with eating disorders (EDs) and obsessive-compulsive disorder (OCD), but its diagnostic status remains unclear. Recent studies suggest ON may be linked to personality traits like perfectionism, common in both EDs and OCD (3,5). The COVID-19 pandemic has exacerbated these issues, stressing the need for better understanding of ON and its overlaps with other disorders (6).ObjectivesThis study reviews literature from the past seven years to explore the connections between ON, EDs, and OCD. It examines ON as a possible distinct diagnosis, focusing on the role of personality traits like perfectionism and evaluates the clinical implications and treatment needs, considering cultural and contextual factors.MethodsA systematic review was conducted using PubMed, PsycINFO, and Scopus, covering studies from 2017 to 2023. The studies included clinical and non-clinical samples, focusing on psychopathological features and personality traits linked to ON, EDs, and OCD (1-2). The review analyzed diagnostic criteria, prevalence, personality trait correlations, and the impact of contextual factors like the COVID-19 pandemic.ResultsON has a complex relationship with EDs and OCD. In ED patients, especially those with anorexia nervosa (AN) and bulimia nervosa (BN), orthorexic behaviors were more prevalent, suggesting ON might be a subtype of EDs rather than a separate condition. ON scores in ED patients decreased after targeted treatment, supporting this connection (1). Personality studies showed that orthorexic individuals often display perfectionism, particularly concerns about mistakes and unrealistic standards. These traits are transdiagnostic, affecting ON, EDs, and OCD (2-3). ON was also linked to specific personality profiles, such as paranoid and narcissistic traits, which worsen symptoms and complicate treatment (2). ON symptoms were strongly correlated with anxiety, depression, and ED and OCD symptoms, indicating shared psychopathological mechanisms (5). The ego-syntonic nature of ON, where behaviors are seen as normal, may lead to underdiagnosis and reduced treatment-seeking (5). The COVID-19 pandemic further exacerbated orthorexic behaviors, highlighting the need for tailored clinical interventions for at-risk individuals (6).ConclusionsON should be viewed within the ED spectrum, with significant overlaps with OCD and influence from traits like perfectionism. Cultural and definitional differences complicate its classification as a distinct disorder. The COVID-19 pandemic has highlighted the clinical importance of ON and the need for effective prevention and treatment strategies. Future research should aim to develop standardized diagnostic criteria and explore personality traits to improve ON diagnosis and treatment.Disclosure of InterestNone Declared

The Behavior of Eating Glass, With Radiological Findings: A Case of Pica

Body-focused repetitive behaviors (BFRBs) and eating disorders (EDs) involve persistent, self-directed behaviors causing distress and impairment. Despite similarities, the relationship between the two is understudied. We examined clinical and subclinical BFRB prevalence in individuals with EDs, tested associations with ED and obsessive-compulsive (OC) symptoms, and compared BFRB occurrence between ED subtypes. The sample included 95 female adults and adolescents in residential ED treatment (51% anorexia nervosa-restricting, 37% anorexia nervosa-binge-eating/purging, 9% bulimia nervosa, 3% other EDs). The Habit Questionnaire, Eating Disorder Examination Questionnaire, and Dimensional Obsessive-Compulsive Scale assessed BFRBs, ED symptoms, and OC symptoms, respectively. BFRBs were highly prevalent in the sample, with 37% meeting clinically significant levels and 31% displaying subclinical BFRBs. The most common clinically significant BFRBs were skin picking (28%), mouth chewing (10%), and hair pulling (9%). Higher ED and OC symptom severity were both associated with the presence of any presence of a co-occurring BFRB. BFRB prevalence did not differ between restricting and binge-eating/purging ED subtypes. Overall, co-occurring BFRBs were common in this residential ED sample, highlighting the need for routine screening. Both ED and OC symptom severity were uniquely related to BFRB occurrence. Future research should explore the underlying mechanisms to better understand the relationship between BFRBs and EDs.

Back to table of contents Previous article Next article Letter to the EditorFull AccessComorbidity of Anxiety With Eating Disorders and OCDNATHALIE GODART, M.D., Ph.D., SYLVIE BERTHOZ, Ph.D., FABIENNE PERDEREAU, M.D., M.S., and PHILIPPE JEAMMET, M.D., Ph.D., NATHALIE GODARTSearch for more papers by this author, M.D., Ph.D., SYLVIE BERTHOZSearch for more papers by this author, Ph.D., FABIENNE PERDEREAUSearch for more papers by this author, M.D., M.S., and PHILIPPE JEAMMETSearch for more papers by this author, M.D., Ph.D., Paris, FrancePublished Online:1 Feb 2006https://doi.org/10.1176/appi.ajp.163.2.326AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor:The article by Walter H. Kaye, M.D., et al. (1) on comorbid anxiety disorders in eating disorders is a considerable contribution to this research area. However, other studies on this topic (2–4) were not referred to. Important information for several points of discussion is raised by these unmentioned studies.We (2) found that 71% of 271 current subjects with eating disorders had lifetime comorbidity with at least one anxiety disorder (64% for Dr. Kaye et al.). The proportion of generalized anxiety disorder that was reported by Dr. Kaye et al. (10%) appears lower than our findings (anorexia nervosa: 45.6%, bulimia nervosa: 31.4%; all current). Converse to their finding, the eating disorders in our study group were all current, which may have affected the comorbidity rates. Given that subjects with a lifetime eating disorder (who are not currently ill) have a ratio of having no anxiety disorder to having an anxiety disorder significantly higher than for people who are currently ill (1), we wonder whether this discrepancy reflects a diagnostic bias instead of a bias of recall or a weak association with recovery. Indeed, high levels of anxiety and depressive symptoms (due to denutrition [5] or other factors, such as duration of illness, social disability, or preexisting trait anxiety) could lead to excessive current diagnoses of anxiety disorder.Obsessive-compulsive disorders (OCDs) were nearly twice as frequent in the study of Dr. Kaye et al. (41%) as in our study (anorexia nervosa: 24.1%) and that of Iwasaki et al. (3). Although we did not use a symptomatic scale and thus may have missed some cases, the study by Iwasaki et al. suggests that it may rather be because the participants in the study by Dr. Kaye et al. “came from enriched pedigrees,” leading to higher rates of comorbidity than in the community (1) or in other eating disorders groups.Dr. Kaye et al. found that 66% of their comorbid cases and 42% of their entire study group had an onset of at least one anxiety disorder before the onset of an eating disorder. Our rates were, respectively, 50% and 33% (2). Although OCD and generalized anxiety disorder usually preceded the onset of an eating disorder in the study by Dr. Kaye et al., we observed the inverse pattern (2). This discrepancy could be due to some memory bias (i.e., people who have durably been characterized by obsessive-compulsive traits may have difficulties in remembering the exact time of the onset of OCD) or to a selection bias. Knowing that unusually precocious age at the onset of OCD is a risk factor for the development of eating disorders (6) and that the group selection of Dr. Kaye et al. was specific, we wonder whether the rate of early-onset OCD in their group of “enriched pedigrees” might have been unusually high.Dr. Kaye et al. reported no differences in the rates of OCD between the patients with anorexia nervosa and those with bulimia nervosa, converse to another of their studies (4) in which they observed higher rates of OCD in patients with anorexia nervosa than in those with bulimia nervosa. In another of our studies (7), current diagnoses of agoraphobia and OCD were significantly more frequent in patients with anorexia nervosa than in those with bulimia nervosa. These contradictory results stress the need for developing further research on the comorbidity between eating disorders and anxiety disorders.

A large and well-characterized sample of individuals with anorexia nervosa and bulimia nervosa from the Price Foundation collaborative genetics study was used to determine the frequency of anxiety disorders and to understand how anxiety disorders are related to state of eating disorder illness and age at onset. Ninety-seven individuals with anorexia nervosa, 282 with bulimia nervosa, and 293 with anorexia nervosa and bulimia were given the Structured Clinical Interview for DSM-IV Axis I Disorders and standardized measures of anxiety, perfectionism, and obsessionality. Their ratings on these measures were compared with those of a nonclinical group of women in the community. The rates of most anxiety disorders were similar in all three subtypes of eating disorders. About two-thirds of the individuals with eating disorders had one or more lifetime anxiety disorder; the most common were obsessive-compulsive disorder (OCD) (N=277 [41%]) and social phobia (N=134 [20%]). A majority of the participants reported the onset of OCD, social phobia, specific phobia, and generalized anxiety disorder in childhood, before they developed an eating disorder. People with a history of an eating disorder who were not currently ill and never had a lifetime anxiety disorder diagnosis still tended to be anxious, perfectionistic, and harm avoidant. The presence of either an anxiety disorder or an eating disorder tended to exacerbate these symptoms. The prevalence of anxiety disorders in general and OCD in particular was much higher in people with anorexia nervosa and bulimia nervosa than in a nonclinical group of women in the community. Anxiety disorders commonly had their onset in childhood before the onset of an eating disorder, supporting the possibility they are a vulnerability factor for developing anorexia nervosa or bulimia nervosa.

Several studies have recently suggested that an abnormal processing of respiratory interoceptive and nociceptive (painful) stimuli may contribute to eating disorder (ED) pathophysiology. Mood and anxiety disorders (MA) are also characterized by abnormal respiratory symptoms, and show substantial comorbidity with ED. However, no studies have examined both respiratory and pain processing simultaneously within ED and MA. The present study systematically evaluated responses to perturbations of respiratory and nociceptive signals across the levels of physiology, behavior, and symptom report in a transdiagnostic ED sample (n = 51) that was individually matched to MA individuals (n = 51) and healthy comparisons (HC; n = 51). Participants underwent an inspiratory breath-holding challenge as a probe of respiratory interoception and a cold pressor challenge as a probe of pain processing. We expected both clinical groups to report greater stress and fear in response to respiratory and nociceptive perturbation than HCs, in the absence of differential physiological and behavioral responses. During breath-holding, both the ED and MA groups reported significantly more stress, feelings of suffocation, and suffocation fear than HC, with the ED group reporting the most severe symptoms. Moreover, anxiety sensitivity was related to suffocation fear only in the ED group. The heightened affective responses in the current study occurred in the absence of group differences in behavioral (breath hold duration, cold pressor duration) and physiological (end-tidal carbon dioxide, end-tidal oxygen, heart rate, skin conductance) responses. Against our expectations, there were no group differences in the response to cold pain stimulation. A matched-subgroup analysis focusing on individuals with anorexia nervosa (n = 30) produced similar results. These findings underscore the presence of abnormal respiratory interoception in MA and suggest that hyperreactivity to respiratory signals may be a potentially overlooked clinical feature of ED.

The role of compulsive exercise in the relationship between perfectionism and eating disorder pathology in underweight adolescents with eating disorders

This study sought to determine if rates of childhood sexual, physical, psychological, and multiple abuse (i.e., abuse in more than one form) differed between women with a lifetime history of bulimia nervosa and women with no history of eating disorders. Subjects were 80 women, aged 18-35, with a lifetime history of bulimia nervosa (40 women who had recovered for a year or more and 40 women currently suffering from bulimia nervosa) and 40 women who had never had an eating disorder or related difficulties. The cohort was obtained primarily by newspaper advertisement. Subjects participated in structured diagnostic interviews and completed paper-and-pencil questionnaires related to abusive experiences in childhood. Women in the bulimia nervosa group reported higher levels of childhood physical, psychological, and multiple abuse. Contrary to expectation, rates of sexual abuse did not distinguish the groups, except in combination with other forms of abuse. The higher rates of psychological, physical, and multiple abuse found among women with a lifetime history of bulimia nervosa than among comparison subjects underscore the importance of examining the full range of possible abusive experiences in women with eating disorders, rather than focusing simply on sexual abuse.

Compared to the general population, adoptees are more often referred to specialist psychiatric treatment, exhibit increased risk of suicide and display more symptoms of attention-deficit/hyperactivity-disorder. However, little is known about the impact of being an adoptee on the risk of developing an eating disorder. The aim of the present study was to assess whether international adoptees have a higher risk for eating disorders than native Swedes. In the present retrospective cohort study, data from the Swedish total population registers on individuals born between 1979 and 2005 were used to assess whether international adoptees residing in Sweden (n = 25 287) have a higher risk for anorexia nervosa (AN) and other eating disorders (OED) than non-adoptees with Swedish-born parents from the general population (n = 2 046 835). The patterns of these results were compared to those for major depressive disorder (MDD), obsessive-compulsive disorder (OCD), and anxiety disorders to determine whether any observed effects were unique to eating disorders or reflected a more general impact on mental health outcomes. A survival analysis adjusting for relevant demographic covariates revealed an elevated risk of all examined psychiatric disorders in international adoptees: hazard ratios (95% confidence intervals) are 1.21 (1.04-1.41) for AN, 1.60 (1.44-1.79) for OED, 1.90 (1.81-2.00) for MDD, 1.25 (1.09-1.44) for OCD, and 1.69 (1.60-1.78) for anxiety disorders. Elevated risk of eating disorders as well as of MDD, OCD, and anxiety disorders was found in international adoptees. A parallel pattern between AN and OCD was observed, which both display less elevated rates than the other diagnoses. A considerable number of biological, environmental, and societal factors have been suggested to explain the observed differences in mental health between adoptees and non-adoptees, but they remain primarily theoretical.

In attempting to explain the familial predisposition to panic disorder, most studies have focused on the heritability of physiologic characteristics (e.g., CO2 sensitivity). A heretofore unexplored possibility is that a psychological characteristic that predisposes to panic-anxiety sensitivity-might be inherited. In this study, the authors examined the heritability of anxiety sensitivity through use of a twin group. Scores on the Anxiety Sensitivity Index were examined in a group of 179 monozygotic and 158 dizygotic twin pairs. Biometrical model fitting was conducted through use of standard statistical methods. Broad heritability estimate of the Anxiety Sensitivity Index as a unifactorial construct was 45%. Additive genetic effects and unique environmental effects emerged as the primary influences on anxiety sensitivity. There was no evidence of genetic discontinuity between normal and extreme scores on the Anxiety Sensitivity Index. This study suggests that one psychological risk factor for the development of panic disorder-anxiety sensitivity-may have a heritable component. As such, anxiety sensitivity should be considered in future research on the heritability of panic disorder.