Beliefs and expectations regarding etiology, treatment and outcome in bulimia nervosa.

OBJECTIVE: To examine pretreatment client beliefs and expectations about the causes of bulimia nervosa (BN), and helpfulness of treatment. The association between outcome expectations, pretreatment characteristics, and treatment outcome was also tested. METHOD: 76 BN clients completed a questionnaire assessing beliefs and expectations before participating in a randomized treatment trial. RESULTS: Clients attributed their BN to problems of dysphoria, low self-esteem, perfectionism, and weight preoccupation. They also anticipated a wide array of therapeutic modalities to be helpful, and expected to make changes within 7 weeks of treatment. Surprisingly, outcome expectations were not related to treatment response. Clients who were identified as treatment optimists were more likely to be older, have a longer duration of illness, and greater pretreatment depression and BN symptomatology. DISCUSSION: These results are discussed in the context of the transtheoretical model, suggesting that veteran BN clients who experience greater complications are less ambivalent and more hopeful about change.

Comparisons of men with full or partial eating disorders, men without eating disorders, and women with eating disorders in the community.

OBJECTIVE: The authors compared 62 men who met all or most of the DSM-III-R criteria for eating disorders with 212 women who had similar eating disorders and 3,769 men who had no eating disorders on a wide variety of clinical and historical variables. METHOD: The groups of subjects were derived from a community epidemiologic survey performed in the province of Ontario that used the World Health Organization's Composite International Diagnostic Interview. RESULTS: Men with eating disorders were very similar to women with eating disorders on most variables. Men with eating disorders showed higher rates of psychiatric comorbidity and more psychosocial morbidity than men without eating disorders. CONCLUSIONS: These results confirm the clinical similarities between men with eating disorders and women with eating disorders. They also reveal that both groups suffer similar psychosocial morbidity. Men with eating disorders show a wide range of differences from men without eating disorders; the extent to which these differences are effects of the illness or possible risk factors for the occurrence of these illnesses in men is not clear.

A randomized controlled trial of fluoxetine and cognitive behavioral therapy for bulimia nervosa: short-term outcome.

This study compared and combined fluoxetine and individual cognitive behavioral therapy in the treatment of bulimia nervosa. Participants were 76 women who sought treatment at the Eating Disorders Program of the Toronto Hospital and who met DSM-III-R criteria for bulimia nervosa. Subjects were randomly assigned to receive fluoxetine alone, cognitive behavior therapy alone, or the two in combination and were treated over 16 weeks. Short-term outcome revealed that all three treatment conditions were associated with clinical improvement across a wide range of parameters. The combination of pharmacotherapy and psychotherapy was superior to pharmacotherapy alone on specific parameters and there was no statistically significant advantage to the combination over psychotherapy alone. Limitations to the study include the absence of a placebo pill group and a waiting list control group as well as a substantial dropout rate across all three treatment conditions.

The early Canadian history of anorexia nervosa.

OBJECTIVE: To examine several early Canadian descriptions of anorexia nervosa (AN) in light of modern understanding of the disorder. METHOD: Two clinical reports of AN from the late 19th century and early 20th century in Canada are cited and summarized. These original case descriptions are then compared with late 20th century knowledge of the disorder. RESULTS: Both of these early descriptions contain many astute and prescient observations on the etiology and sequelae of AN and reveal a compassionate approach to patient care. CONCLUSIONS: Canadian contributions to the medical literature on AN prior to 1970 merit both careful scrutiny and appreciation in the world literature on this disorder.

Rediscovering general psychiatry: creation of an academic division.

OBJECTIVE: To describe the rationale, origins, and goals of a newly created academic division of general psychiatry within a university setting. METHOD: Literature review, observation, and description. RESULTS: Within 2 years of its inception, the General Psychiatry Division of the University of Toronto has begun to realize some of its goals and further elucidate specific objectives. CONCLUSIONS: In an era of increasing academic subspecialization, the preservation of core skills in psychiatry and the recognition of the continuing public need for psychiatric generalists must be enshrined within academic training programs.

Cerebral gray matter and white matter volume deficits in adolescent girls with anorexia nervosa.

OBJECTIVES: This study was undertaken to determine whether the increased cerebrospinal fluid (CSF) volumes found in anorexia nervosa (AN) are the result of differences in gray matter or white matter volumes or both. METHODS: Thirteen adolescent girls with AN who were receiving inpatient care at a tertiary-care university children's hospital and eight healthy female control subjects were studied by using magnetic resonance imaging. Images were processed by means of software developed to classify all pixels as either CSF, gray matter, or white matter. Pixels of each class were then summed across all sections. RESULTS: The AN group had larger total CSF volumes in association with deficits in both total gray matter and total white matter volumes. Lowest reported body mass index was inversely correlated with total CSF volume and positively correlated with total gray matter volume. Urinary free cortisol levels were positively correlated with total CSF volume and inversely correlated with central gray matter volume. CONCLUSIONS: These findings add support to the view that the brain abnormalities found in AN are in large part the result of the effects of the illness. The extent to which these differences in gray matter and white matter volumes are reversible with recovery remains to be established.

Purging and nonpurging forms of bulimia nervosa in a community sample.

OBJECTIVE: Recent consensus on the subclassification of the eating disorder bulimia nervosa into purging and nonpurging forms is examined in the context of a large psychiatric epidemiological survey in Ontario, Canada. METHOD: Among a sample of 8,116 individuals, 62 met criteria for bulimia nervosa. Of these, the 17 who were of the purging subtype could be distinguished from the nonpurging group on a variety of parameters of comorbidity, family history, and childhood environment. RESULTS: The purging subtype was distinguishable on the basis of early age of onset, and high rates of affective disorders and anxiety and alcoholism, sexual abuse, and parental discord. DISCUSSION: The data support the taxonomy and point to the need for better understanding of the meaning of purging behavior.

Psychiatric practice for the coming decade.

OBJECTIVE: To identify important trends and themes that will affect psychiatric training and practice. METHOD: Selective literature review and reflections by the authors. RESULTS: Three principal themes are elucidated relating to empiricism and integration, accountability and collaboration, and training and the public trust. CONCLUSIONS: There must be debate and action on these and other themes to maintain the relevance of psychiatry to its changing context.

The hormonal response to intravenous 5-hydroxytryptophan in bulimia nervosa.

In recent years evidence has accumulated to implicate a disturbance in serotonin function in the eating disorder bulimia nervosa. This study employs a neuroendocrine technique to assess the effect of intravenous 5-hydroxytryptophan, the immediate precursor to serotonin, on peripheral hormones in bulimia nervosa subjects and controls. Blunted prolactin and growth hormone responses were observed among bulimia nervosa subjects; the possible pathophysiology and implications of the findings are discussed.

Bulimia nervosa in a Canadian community sample: prevalence and comparison of subgroups.

OBJECTIVE: Previous epidemiological studies of bulimia nervosa have generated differing estimates of the incidence and prevalence of the disorder. These differences are attributable, in part, to varying definitions of the illness and a range of methodologies. The authors sought to define the prevalence of bulimia nervosa in a nonclinical community sample, examine the clinical significance of DSM-III-R threshold criteria, and examine comorbidity. METHOD: Subjects across Ontario (N = 8,116) were assessed with a structured interview, the World Health Organization Composite International Diagnostic Interview, with specific questions added for bulimia nervosa. Subjects who met DSM-III-R criteria for bulimia nervosa were compared with those who were missing only the frequency criterion (two or more binge-eating episodes per week for 3 months). RESULTS: In this sample, the lifetime prevalence of bulimia nervosa was 1.1% for female subjects and 0.1% for male subjects. The subjects with full- and partial-syndrome bulimia nervosa showed significant vulnerability for mood and anxiety disorders. Lifetime rates of alcohol dependence were high in the full-syndrome group. Rates of parental psychopathologies were high in both bulimic groups but tended to be higher in the subjects with full-syndrome bulimia nervosa. Both bulimic groups were significantly more likely to experience childhood sexual abuse than a normal female comparison group. CONCLUSIONS: This study confirms other prevalence estimates of bulimia nervosa and its comorbid diagnoses from studies that were based on sound methodologies. It also points to the arbitrary aspects of the frequency of binge eating as a diagnostic threshold criterion for the disorder.

Correlations of plasma and urinary phenylacetic acid and phenylethylamine concentrations with eating behavior and mood rating scores in brofaromine-treated women with bulimia nervosa.

Women with bulimia nervosa undergoing treatment with the reversible monoamine oxidase type A inhibitor, brofaromine, were rated for mood and eating behaviour and their plasma and urine were assessed for phenylacetic acid (unconjugated and total) and unconjugated phenylethylamine prior to and after four weeks of drug treatment. Changes in plasma unconjugated phenylacetic acid concentrations were significantly and negatively correlated with the corresponding changes in Hamilton Depression scores but not with eating behavior measures. There were no significant correlations between changes in phenylethylamine levels and changes in rating scores. Patients diagnosed as suffering concurrently from severe depression (Hamilton Depression score of 17 or higher) had lower plasma and urinary phenylacetic acid levels than did those whose depression was not severe (Hamilton score less than 17). Phenylethylamine concentrations were not different between the severely and mildly depressed subgroups. The results confirm earlier studies on the relationship between phenylacetic acid and depression while showing that a similar relationship does not pertain to phenylacetic acid and eating behavior in bulimia nervosa.

Advances in the Treatment of Anorexia Nervosa and Bulimia Nervosa.

During the last decade, much investigation into possible pharmacotherapy for eating disorders has been undertaken, especially for bulimia nervosa.Intensive hospital treatment compromising a combination of individual, group and family therapies with or without adjunctive pharmacological treatments are usually offered in anorexia nervosa. Osteoporosis and delayed gastric emptying are 2 medical complications that should be addressed as early as possible in the course of the disorder. Although not yet confirmed in controlled clinical trials, there is preliminary support for the use of hormone replacement therapy for anorexic patients with amenorrhoea. The short term use of prokinetic agents such as cisapride or domperidone may assist in the refeeding process.Despite several controlled clinical trials involving antipsychotic and antidepressant drugs, there is no pharmacological agent that has demonstrated superiority in enhancing the rate of bodyweight gain. Recently, uncontrolled and unblinded trials with fluoxetine in anorexia nervosa have offered promising results. However, further double-blind controlled evaluation is necessary to properly evaluate the role of fluoxetine or other selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SSRIs) in treating anorexia nervosa.In contrast to the limited literature on the treatment of anorexia nervosa, there have been a series of controlled clinical trials investigating treatments for bulimia nervosa. These have involving different forms of psychotherapy, both individual and group formats, or pharmacotherapy. Several investigators have also reported on the benefits of combining drug and psychological treatment in comparison to either approach on its own.SSRIs, monoamine oxidase inhibitors and tricyclic antidepressants have all been shown to offer symptomatic improvement in trials lasting between 6 and 24 weeks. A 24-week clinical trial of desipramine combined with individual cognitive therapy produced the best outcome.It is hoped that over time, with reduced cultural pressures to diet and with more emphasis on early detection of those individuals at risk of developing eating disorders, the occurrence and complications of these disorders will be reduced. Treatment research in the next decade will hopefully include clinical and biological predictors of response, meaningful long term outcome assessment, and novel interventions that will minimise the significant morbidity and mortality of these illnesses.

Is there a role for selective monoamine oxidase inhibitor therapy in bulimia nervosa? A placebo-controlled trial of brofaromine.

Pharmacologic and cognitive behavioral therapies have been advocated in the treatment of bulimia nervosa (BN). Brofaromine, a selective and reversible inhibitor of monoamine oxidase-A was selected for a double-blind, placebo-controlled evaluation because of previous demonstrated monoamine oxidase inhibitor efficacy in BN and because of its safer adverse reaction profile. Thirty-six female patients who met DSM-III-R criteria for BN were randomly assigned to the drug group (N = 19) or to the placebo group (N = 17) for an 8-week outpatient trial. Brofaromine produced a significant effect in decreasing episodes of vomiting throughout the trial, although comparable reductions in episodes of binge eating were found in both groups. Also, there were no advantages of drug over placebo on improvements in attitudinal measures and shape or on self-report ratings of depression and anxiety. However, a significant proportion of the subjects on brofaromine lost weight when compared with the placebo group. Methodologic issues including subjective assessment measures, placebo response rates, and the elucidation of responder subgroups are discussed.

The effect of the MAO-A selective inhibitor brofaromine on the plasma and urine concentrations of some biogenic amines and their acidic metabolites in bulimia nervosa.

1. Brofaromine or placebo were administered to female bulimia nervosa patients over a period of eight weeks. Plasma and urinary trace amines, their acidic metabolites and the acidic metabolites of the catecholamines and serotonin were assessed prior to treatment and at four and eight weeks after commencement of treatment. 2. The levels of both plasma and urinary homovanillic and vanilmandelic acids declined significantly during the first four weeks of treatment with brofaromine and then partially recovered to pre-drug levels by the eighth week. 5-Hydroxyindoleacetic acid levels were not affected by drug treatment at the times assessments were made. Urinary tryptamine increased significantly during the first four weeks of brofaromine treatment then partially recovered towards pre-drug levels by the eighth week. No effect from placebo treatment was observed.