Suicidal behaviour and nonsuicidal self-injury among patients with eating disorders

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

Eating Disorders: What Are the Risks?

The evolving epidemiology and differential etiopathogenesis of eating disorders: implications for prevention and treatment.

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.

Data on the stability of eating disorder (ED) diagnoses (DSM-IV) over 12 years are presented for a large sample (N = 311) of female eating disordered patients with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). Assessments were made at the beginning of therapy and 2-, 6-, and 12-year follow-ups. Diagnoses were derived from the Structured Inventory for Anorexic and Bulimic Eating Disorders. Possible diagnostic outcome categories were AN, BN, BED, NOS, no ED, and deceased. At all follow-ups, more patients changed from AN or BED to BN than vice versa. No diagnostic crossover from AN to BED or vice versa occurred. BED showed the greatest variability and AN had the greatest stability over time. While the long-term outcome of BN and BED is similar, AN had a considerably worse long-term outcome than either BN or BED. Of the ED diagnoses, AN was most stable and BED most variable. The considerable diagnostic flux between BN and BED and similarities in course and outcome of BN and BED point to common biological and psychological maintaining processes. AN and BED are nosologically quite distant.

Cigarette smoking is associated with severe mental illness, including schizophrenia and bipolar disorder, and with morbidity and mortality, but the association with anorexia (AN), bulimia nervosa (BN) and binge eating disorder (BED) is unclear. This meta-analysis compared the odds of smoking in eating disorders (ED) (ED = AN or BN or BED) versus healthy controls (HC) and calculated the prevalence of smokers in people with ED. Three independent authors searched PubMed, MEDLINE and Scopus from database inception until 31 December 2015 for studies reporting data on life-time or current smoking prevalence in BED, BN and AN with or without control group. Meta-analyses were undertaken, calculating odds ratios (ORs) of life-time smoking in BED, BN, AN versus healthy controls (HCs) or prevalence of smoking in BED, BN and AN with 95% confidence intervals (CI). Thirty-one studies (ED = 8517, controls = 68 335) were meta-analysed. Compared with HCs, there were significantly more smokers among people with BN (life-time OR = 2.165) and BED (life-time OR = 1.792) but not AN (life-time OR = 0.927). BED was associated with smoking the most (life-time prevalence = 47.73%) followed by BN (life-time prevalence = 39.4%) and AN (life-time prevalence = 30.8%). In BN, life-time smoking prevalence was highest in Europe. In AN, higher age moderated both life-time and current smoking prevalence, and body mass index moderated higher life-time smoking prevalence. In BN, female sex moderated higher life-time smoking prevalence. People with binge eating disorder and bulimia nervosa are significantly more likely to be life-time smokers than healthy controls, which is not the case for anorexia nervosa.

Does cognitive behavioral therapy without pharmacotherapy improve eating disorder remission rates?

BackgroundCurrently, we know little regarding how stigma attributed to eating disorders compares to that of other psychological disorders and additionally within different types of eating disorders. In the current study, we aimed to explore the stigmatisation of eating disorders by comparing the stigma attributed to anorexia nervosa, bulimia nervosa, and binge-eating disorder, utilising depression as a comparative control.MethodsA total of 235 participants from the general population were randomly assigned to an anorexia nervosa, bulimia nervosa, binge-eating disorder, or depression condition. Participants responded to a questionnaire consisting of several adapted versions of pre-existing subscales that measured levels of stigma associated with psychological disorders generally, as well as stigma associated with eating disorders specifically. We used several one-way analyses of variance to investigate the differences in stigma attributed towards the aforementioned psychological disorders.ResultsResults suggested that all three eating disorders were significantly more stigmatised than was depression. Between the eating disorders, the three were generally equivalent except that binge-eating disorder was significantly more stigmatised than both anorexia nervosa and bulimia nervosa on a subscale measuring trivialness.ConclusionsThese findings indicate that individuals with eating disorders, including binge-eating disorder, may be at a higher risk of experiencing the negative implications of stigma when compared to other psychological disorders, such as depression. To our knowledge, this study is one of few that directly quantify and compare stigma attributed towards anorexia nervosa, bulimia nervosa, and binge-eating disorder. Through further research, a better understanding around the expression of stigma towards specific eating disorders could inform the development of targeted interventions to help reduce the stigma associated with these disorders. This knowledge could also advance the understanding of the lived experience of individuals living with eating disorders, subsequently informing treatment practices.

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessImproved Eating-Disorder Treatments on HorizonJoan Arehart-TreichelJoan Arehart-TreichelPublished Online:2 Sep 2005https://doi.org/10.1176/pn.40.17.00400013Walter Kaye, M.D.: “Genes play a much stronger role in anorexia nervosa than initially thought.” Photo courtesy of the University of Pittsburgh Medical CenterTerri M. was a “terrific young girl” with a perfectionist personality who developed early symptoms of exercising anorexia nervosa at age 8. Three years later, she had full-blown anorexia, Joel Yager, M.D., a professor of psychiatry at the University of New Mexico and an eating disorder authority, recalled in an interview with Psychiatric News.“Her mother had also had the disorder in college,” Yager added.“ Both her mother and father are thin, high-achieving compulsive athletes to this day, as are all of their friends.”Can Terri's anorexia nervosa be blamed on genes? The influence of her parents? Or other factors? Probably all three, research results suggest,“ although genes play a much stronger role in anorexia nervosa than initially thought,” Walter Kaye, M.D., a professor of psychiatry at the University of Pittsburgh and an anorexia expert, told Psychiatric News.Nonetheless, there are still a number of puzzling questions about the origins of anorexia nervosa, a condition that has been medically recognized since the late 19th century. In fact, a lot still remains to be learned not just about the sources of anorexia nervosa, but also about those of the two other recognized eating maladies— bulimia nervosa, first identified in 1979 and included in DSM-III, and binge-eating disorder, included in the DSM-IV as a provisional disorder.For instance, ample evidence has revealed that eating disorders occur predominantly in developed countries, prompting eating-disorder experts to suspect that certain cultural or social factors in developed countries are at least partially responsible for the illnesses. Yet little research has divulged which cultural or social factors might be the culprits.Moreover, there are no firm data about the prevalence of eating disorders in the United States and thus no way of knowing whether the prevalence of eating disorders has changed in recent years.“I wish we had such data,” said David Herzog, M.D., a professor of psychiatry at Harvard Medical School and an eating disorder authority.“ It is a limitation in our field.”In fact, it is not even known whether more Americans are seeking treatment for eating disorders today than five or 10 years ago. “I am not aware of any data to show changing trends in help-seeking behavior,” said Yager.“ This is very complex and has to do with changing awareness—which might increase help-seeking behavior—and issues concerning access to care, both availability of trained specialists and insurance or other means to pay for care.”Better Treatments Available TodayThe good news, however, is that there are more ways to help individuals with eating disorders today than there were 20 years ago.For instance, there is strong evidence to support the value of family involvement in the treatment of anorexia nervosa patients under the age of 18. It is also now known that after anorexia nervosa patients have regained weight—with the help of families and/or with the help of staff in eating disorders programs—that the risk of relapse can be reduced with psychotherapy, particularly cognitive-behavioral therapy (CBT), and with fluoxetine, and presumably other SSRI antidepressants as well, said Yager.The treatment of choice for bulimia nervosa is CBT, whose effectiveness is now supported by more than a dozen studies. Scientific evidence has also revealed that if bulimia nervosa patients are treated with both CBT and an SSRI, they do even better than if they get CBT alone, Yager said.As for binge-eating disorder, CBT is quite successful is halting the binging, but it is not so effective in helping people achieve a healthy weight over the long term, according to James Mitchell, M.D., president of the Neuropsychiatric Research Institute at the University of North Dakota.Other Therapies in OffingStill other effective therapies for eating disorders may become available soon as scientists make inroads in understanding the illnesses.A case in point: Kaye and his coworkers recently found that two types of dopamine receptors—D2 and D3—are more active in the basal ganglia area of the brains of anorexia nervosa subjects than in the basal ganglia area of the brains of subjects who don't have the illness. The researchers also found that the gene that makes the D2 receptors is abnormal in some anorexia nervosa subjects. Kaye and his group thus suspect that dopamine overactivity may underlie anorexia nervosa and that medications that block dopamine receptors in the brain—say, second-generation antipsychotics—might be of some benefit to persons with the illness. The second-generation antipsychotics are also known to promote weight gain, which patients with anorexia nervosa desperately need.However, “there have not been any double-blind, placebo-controlled trials of atypical antipsychotic medications in anorexia nervosa subjects,” Kaye said. “That is one thing that really needs to be done.”Yager agreed. “We know that some clinicians are starting to use atypical antipsychotic medications to help facilitate weight gain in malnourished anorexia nervosa patients, but we still lack both controlled trials and long-term studies to show whether these have any true added value and/or sustaining power that may outweigh potential adverse reactions to taking these medications. Thus, during the next five or 10 years, we can anticipate trials of atypical antipsychotics for acute anorexia nervosa.”Regarding promising new treatments for bulimia nervosa, Mitchell and colleagues conducted a study of 117 subjects with the disorder to see whether conducting CBT via telepsychiatry is as effective, and as acceptable, as when it is conducted face to face. The answer was yes on both counts, Mitchell reported at APA's 2005 annual meeting in May.Regarding propitious new therapies for binge-eating disorder, Susan McElroy, M.D., a professor of psychiatry at the University of Cincinnati, and coworkers enrolled 61 obese subjects with binge-eating disorder in a 14-week randomized, double-blind, placebo-controlled study in which subjects received either the anticonvulsant topiramate or a placebo. Those who completed the study were also offered participation in a 42-week, open-label extension trial of topiramate.Forty-three subjects from both the double-blind study and the open-label trial provided outcome measures. The average duration of topiramate treatment was 21 weeks. From baseline to outcome, all of them experienced a significant decrease in binge eating and in weight, McElroy and her team reported in the November 2004 Journal of Clinical Psychiatry.Nonetheless, the researchers admitted, a fairly large number of subjects dropped out of their study and trial, either because of protocol nonadherence or because of adverse side effects from topiramate.Noncompliance can also pose a dilemma in anorexia nervosa trials. For example, Katherine Halmi, M.D., a professor of psychiatry at Weill Cornell Medical College, and colleagues enrolled 122 patients with the illness in a study in which subjects received CBT, an SSRI antidepressant, or both for a year. The dropout rate was 56 out of 122, or 46 percent, they reported in the July Archives of General Psychiatry.Sometimes it is difficult to get eating-disorder patients to enter treatment trials in the first place. For instance, several years ago Michael Devlin, M.D., clinical codirector of eating disorders research at New York State Psychiatric Institute, and coworkers attempted to recruit obese individuals with a binge-eating problem into a treatment trial in which CBT or an SSRI would be tested as add-on therapy to a more traditional weight-loss program. The program emphasized mostly healthy eating, a healthy lifestyle, self-acceptance, and, to a lesser degree, weight loss.“Often they would call up, express interest, make an appointment for intake, but then wouldn't show up,” Devlin said in an interview. The reason why, he suspected, is that “many obese people have had so many disappointing experiences with dieting that they feel very discouraged.”Often individuals with eating disorders do not want treatment at all. This is especially true for persons with anorexia nervosa who are over 18 years of age, Halmi told Psychiatric News. That is why treating them before they turn 18 is so crucial, she explained, and why family involvement in treatment before they turn 18—the age of majority—is also so vital.Thus, finding some way to motivate eating-disorder patients both to seek treatment and to stick with it would surely constitute a“ breakthrough” in the conquest of eating disorders. And when all is said and done, motivation may be as crucial as treatment per se.Take the case of 35-year-old “Cindy T.,” who had anorexia nervosa since age 13. She had osteoporosis, had lost most of her teeth, and had been close to dying on several occasions. “A lot of people had given up on her,” Mitchell said. “But she eventually recovered and is doing very well now.”“Part of the reason why she did recover,” Mitchell observed,“ was her own motivation to change. She was tired of living her life that way and made a commitment to do things differently.” ▪ ISSUES NewArchived

Background Eating Disorders (EDs) comprise a significant portion of the mental health morbidity of young people, yet underdetection is a major problem. To identify and tackle the barriers to service engagement, health promotion initiatives require concrete information about how EDs are viewed by adolescents. This study sought to explore young people’s ED literacy and their attitudes towards people with EDs. Methods Ethical approval was granted by St John of God Research Ethics Committee. 260 schools from across Ireland were invited to participate. 63 schools agreed to recruit students to the survey, which could be completed either online or on paper. Participants were randomly allocated to view one of five vignettes depicting a young person with symptoms consistent with Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BED), Depression or Type 1 Diabetes. Participants were asked to identify the illness described. They also indicated their beliefs regarding illness duration, level of personal control over the illness, likely causes of the illness, and the target’s personal characteristics. Differences between the vignette conditions were explored in SPSS via chi-square tests (for categorical variables) and analyses of variance with post hoc Bonferroni-corrected comparisons (for continuous variables that met the necessary statistical conditions). Results 290 students completed the survey. Participants were aged between 15–19 ( M = 16.76, SD = 0.89), attended a range of school types (single-sex/mixed-sex, public/private), and 51% were female. Six participants had been affected by an ED themselves, and 62.4% knew someone with an ED. However, responses to the vignettes showed poor recognition of the symptoms of EDs in comparison with Depression ( χ² [4, n = 2 83] = 36.125, p .001). Only small minorities of those who encountered the AN (20.4%), BN (12.5%) and BED (0%) vignettes correctly named the illness described. Analysis of the attitude variables showed that all three EDs were seen as significantly longer in duration than Depression ( F [4,267] = 6.208, p .001). All three EDs were rated more individually-caused than either Depression or T1 Diabetes ( F [4,269] = 18.53, p .001), and participants believed that the BED target had significantly more personal control over their disorder than the Depression or T1 Diabetes targets ( F [4,264] = 3.56, p = 0 .008). All three ED targets were ascribed significantly less positive personality traits than the T1 Diabetes target ( F [4,255] = 12.91, p .001). Conclusion The results indicate the need for greater public education regarding the symptoms of EDs, so that young people can identify and seek help for problematic eating in themselves and their peers. Health promotion initiatives should also address the stigmatising or blaming attitudes to EDs that can inhibit detection and treatment, particularly the perception that EDs are self-inflicted.

PurposeChildhood maltreatment (CM) experiences are associated with heightened risk of Eating disorders (EDs). The psychopathological pathways promoting this association in people with Bulimia nervosa (BN) and in those with Binge eating disorder (BED) are under-investigated.MethodsOne hundred and eighty-one people with BN and 144 with BED filled in the Eating Disorder Inventory-2, to measure ED psychopathology, and the Childhood Trauma Questionnaire, to assess their early traumatic experiences. Network analysis was conducted to investigate the interplay between those variables. The shortest pathways function was employed to investigate the shortest out of all routes conveying the association between CM and ED-specific symptoms.ResultsIn both people with BN and with BED, all CM types were connected to the ED psychopathology through the emotional abuse node. The association between emotional abuse and ED-specific symptoms (bulimia and body dissatisfaction) differed in the two groups: in people with BN, it included ineffectiveness, while in people with BED, it involved impulsivity. Interoceptive awareness, an indirect measure of emotion regulation, was included in these pathways in both groups.ConclusionIn the light of literature showing that emotional abuse has a connecting role between CM and ED psychopathology also in anorexia nervosa, the present findings support the idea that emotional abuse conveys such association in all the main ED diagnoses. Ineffectiveness and impulsivity may represent the specific psychopathological dimensions connected to emotional abuse and promoting the maintenance of ED-specific symptoms in BN and in BED, respectively. These findings are worth of attention by clinicians.Level of evidenceLevel III: evidence obtained from well-designed cohort or case–control analytic studies

The purpose of this investigation was to establish the criterion validity of the Multiaxial Assessment of Eating Disorders Symptoms (MAEDS). The MAEDS is a brief, comprehensive, self-report measure for the evaluation of eating disorders treatment outcome. It assesses six symptoms associated with eating disorders with subscales for binge eating, purgative behavior, avoidance of forbidden foods, restrictive eating, fear of fatness, and depression. To establish criterion validity, we compared the subscale scores of the MAEDS across four eating disorder diagnoses, specified by subtype (bulimia nervosa, purging type; anorexia nervosa, binge-eating/purging type; anorexia nervosa, restricting type; and binge eating disorder). Participants who did not meet the full diagnostic criteria for an eating disorder, but who did meet criteria for a partial syndrome eating disorder, were grouped with the full eating disorder diagnostic subtypes. The criterion validity of the MAEDS was supported by the pattern of subscale scores for the different eating disorder diagnostic groups. Also, with few exceptions, persons diagnosed with anorexia nervosa, bulimia nervosa, and binge eating disorder, in comparison to subthreshold cases of anorexia nervosa, bulimia nervosa, and binge eating disorder, had equivalent scores on the subscales of the MAEDS. These findings support the criterion validity of the MAEDS and add to a growing literature that questions differences in severity of eating disorder symptoms in full syndrome versus partial syndrome cases.

Anxiety and Disordered Eating

Glial cells exhibit multifaceted functions and represent essential contributors to various physiological processes in the brain, rather than just being silent supportive cells to neurons. Different glial populations of the central nervous system within involved brain regions play various functions, express different proteins, and result in fluctuating effects when altered. Glial cell pathologies were detected in most mental disorders including suicidal behavior. Suicidal behavior represents a health problem of high importance worldwide, where protective measures are required to be taken at many levels. Studies on patients with mental disorders that represent risk factors for suicidal behavior revealed multiple changes in the glia at diverse levels, including variations regarding the expressed glial markers. This review summarizes the role of glia in some psychiatric disorders and highlights the crosslink between changes at the level of glial cells and development of suicidal behavior in patients with an underlying psychiatric condition; in addition, the interplay and interconnection between suicidal behavior and other mental diseases will shed light on the routes of personalized therapy involving the development of glia-related drugs.

Anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) are the three most common eating disorders (EDs). Their etiopathogenesis is multifactorial where both the environmental and genetic factors contribute to the disease outcome and severity. Several polymorphisms in genes involved in the dopaminergic pathways seem to be relevant in the susceptibility to EDs, but their role has not been fully elucidated yet. In this study, we have analyzed the association between selected common polymorphisms in the DRD2 and DRD4 genes in a large cohort of Italian patients affected by AN (n = 332), BN (n = 122), and BED (n = 132) compared to healthy controls (CTRs) (n = 172). Allelic and genotypic frequencies have been also correlated with the main psychopathological and clinical comorbidities often observed in patients. Our results showed significant associations of the DRD2-rs6277 single nucleotide polymorphism (SNP) with AN and BN, of the DRD4-rs936461 SNP with BN and BED and of DRD4 120-bp tandem repeat (TR) polymorphism (SS plus LS genotypes) with BED susceptibility. Moreover, genotyping of DRD4 48-bp variable number TR (VNTR) identified the presence of ≥7R alleles as risk factors to develop each type of EDs. The study also showed that ED subjects with a history of drugs abuse were characterized by a significantly higher frequency of the DRD4 rs1800955 TT genotype and DRD4 120-bp TR short-allele. Our findings suggest that specific combinations of variants in the DRD2 and DRD4 genes are predisposing factors not only for EDs but also for some psychopathological features often coupled specifically to AN, BN, and BED. Further functional research studies are needed to better clarify the complex role of these proteins and to develop novel therapeutic compounds based on dopamine modulation.