Differences in DSM-III-R and DSM-IV diagnoses in eating disorder patients.

Two hundred eighty-eight eating disorder patients were administered the DSM-III-R Structured Clinical Interview (SCID) and the DSM-IV SCID for axis I and II. Concordance between DSM-III-R and DSM-IV was excellent for the axis I affective and anxiety disorders, bulimia nervosa, and substance abuse/dependence. It was also excellent for axis II paranoid, schizoid, borderline, and antisocial personality disorders. Agreement between the two nosological systems was lower for alcohol abuse/dependence with a kappa of.63. Kappas were also poor for the following personality disorders: schizotypal (.44), histrionic (.29), dependent (.54), obsessive-compulsive (.62) and not otherwise specified (.63). There was a substantial difference in the diagnosis of anorexia nervosa between DSM-III-R and DSM-IV. Fourteen patients were diagnosed with anorexia nervosa, binge/purge type, using DSM-IV criteria, while only six received the diagnoses of anorexia nervosa and bulimia nervosa using DSM-III-R criteria. Kappa was.49 and the percent agreement was 79%. While there are considerable areas of overlap in DSM-IV and DSM-III-R, there are also areas of substantial differences. Clinicians and researchers must be very cautious when attempting to compare data from the different nosologies.

Neurocognitive evidence favors "top down" over "bottom up" mechanisms in the pathogenesis of body size distortions in anorexia nervosa.

Perceptually-based disturbances in body image, or body size distortions, have been posited to occur in anorexia nervosa (AN). Perception does not result from a simple flow of sensory information from periphery to cortex ("bottom-up" processing), but involves the selection of inputs most likely to be relevant in light of an individual's experience and expectations ("top-down" processing). Most investigations of body size distortion in AN have used procedures likely to engage top-down processing, raising the possibility that attitudinal disturbances may play a role. To our knowledge, there have been no studies that assess the presence, in AN, of neurocognitive deficits associated with neurologically based disturbances in body schema. Such deficits, if found, could provide evidence of body image distortion unlikely to result from top-down processing. We tested 20 inpatients with AN on measures of proprioception, finger identification, right/left orientation, general cognition and eating disorders symptomatology, both before and after treatment. Matched normal controls were tested on the same measures over the same time intervals. Significant differences between the two groups occurred only prior to treatment, and only on those measures which involved executive, in addition to more body-schema-specific functions. This suggests that patients with AN do not have enduring deficits in the domain of body-schema, but may have subtle cognitive dysfunction, in the acute state, which is not specific to, but can interact with processing of body-schema-related information. This, in turn, suggests that their body image distortion may not be secondary to bottom-up perceptual disturbances.

Changing patterns of hospitalization in eating disorder patients.

OBJECTIVE: This study investigated the changing patterns of hospitalization of eating disorder patients over the past 15 years. METHOD: The records of 1,185 eating disorder patients between 1984 and 1998 were examined on several variables. RESULTS: Over the 15 years, the number of first admissions increased from 20 to 182. There was a concomitant decrease in length of stay from 149.5 days in 1984 to 23.7 days in 1998. Readmissions increased markedly from 0% during the first year to 27% of total admissions in 1998. The discharge weight of anorectic patients significantly decreased from a body mass index (BMI) of 19.3 in 1984 to 17.7 in 1998. These changes were particularly salient in the past 3 years, concurrent with a dramatic rise in managed care cases. CONCLUSIONS: Over the past 15 years, eating disorder hospital treatment has metamorphozed from long-term treatment of a disorder to stabilization of acute episodes. For some patients, this change has been deleterious and not cost effective.

Perfectionism in anorexia nervosa: variation by clinical subtype, obsessionality, and pathological eating behavior.

OBJECTIVE: The purpose of this study was to examine the role of perfectionism as a phenotypic trait in anorexia nervosa and its relevance across clinical subtypes of this illness. METHOD: The Multidimensional Perfectionism Scale and the perfectionism subscale of the Eating Disorder Inventory were administered to 322 women with a history of anorexia nervosa who were participating in an international, multicenter genetic study of anorexia nervosa. All participants were additionally interviewed with the Yale-Brown Obsessive Compulsive Scale and the Yale-Brown-Cornell Eating Disorder Scale. Mean differences on dependent measures among women with anorexia nervosa and comparison subjects were examined by using generalized estimating equations. RESULTS: Persons who had had anorexia nervosa had significantly higher total scores on the Multidimensional Perfectionism Scale than did the healthy comparison subjects. In addition, scores of the anorexia subjects on the Eating Disorder Inventory-2 perfectionism subscale exceeded Eating Disorder Inventory-2 normative data. For the anorexia nervosa participants, the total score on the Multidimensional Perfectionism Scale and the Eating Disorder Inventory-2 perfectionism subscale score were highly correlated. Total score on the Multidimensional Perfectionism Scale was also significantly related to the total score and the motivation-for-change subscale score of the Yale-Brown-Cornell Eating Disorder Scale. CONCLUSIONS: These data show that perfectionism is a robust, discriminating characteristic of anorexia nervosa. Perfectionism is likely to be one of a cluster of phenotypic trait variables associated with a genetic diathesis for anorexia nervosa.

Comparison of the yale-brown-cornell eating disorders scale in recovered eating disorder patients, restrained dieters, and nondieting controls.

OBJECTIVE: Yale-Brown-Cornell Eating Disorder Scale (YBC-EDS) scores were assessed in recovered eating disorder patients, restrained dieters, and unrestrained nondieters. METHOD: YBC-EDS interviews were conducted with 53 recovered eating disorder patients who had no symptoms within at least 6 months, 29 restrained dieters, and 36 unrestrained controls. RESULTS: Unrestrained control subjects had no typical eating-disordered preoccupations or rituals. The majority (62%) of restrained dieters did have current eating-disordered preoccupations but only 5 had current eating-disordered rituals. Most recovered eating disorder subjects had no current eating-disordered preoccupations (66%) and 76% had no current eating-disordered rituals. Unrestrained eating controls had significantly lower Preoccupation, Total, and Motivation to Change scores on the YBC-EDS than the other groups and significantly lower Ritual scores than the recovered eating disorder group. There were no significant differences between the restrained dieters and the recovered eating disorder group. DISCUSSION: Recovered eating disorder patients who no longer meet any of the DSM-IV criteria for an eating disorder are similar in severity of eating concern to normal weight restrained eating dieters. Both of these groups have more eating and weight concerns as compared with the unrestrained eating, nondieting controls. The YBC-EDS effectively distinguishes the healthy eating controls from restrained eating dieters and recovered eating disorder patients.

Bright light therapy decreases winter binge frequency in women with bulimia nervosa: a double-blind, placebo-controlled study.

The study objective was to determine the effect of winter bright light therapy on binge and purge frequencies and depressive symptoms in subjects with bulimia nervosa. Thirty-four female bulimic outpatients were treated with either 10,000 lux bright white light or 50 lux dim red light (placebo control) during the winter months. In this double-blind study, the placebo group (n = 18) and the bright light group (n = 16) were matched for age, degree of seasonality (measured by the Seasonal Patterns Assessment Questionnaire [SPAQ]), and concurrent depression (measured by Structured Clinical Interview for DSM-IV [SCID]). Three weeks of baseline data collection were followed by 3 weeks of half-hour daily morning light treatment and 2 weeks of follow-up evaluation. There was a significant light-treatment by time interaction (Wilks' lambda = .81, F(2,28) = 3.31, P = .05). The mean binge frequency decreased significantly more from baseline to the end of treatment for the bright light group (F(1,29) = 6.41, P = .017) than for the placebo group. The level of depression (measured by daily Beck Depression Inventory [BDI] scores) did not significantly differ between the groups during any phase, and neither depression nor seasonality affected the response to light treatment. In this double-blind study, bulimic women who received 3 weeks of winter bright light treatment reported a reduced binge frequency between baseline and the active treatment period in comparison to subjects receiving dim red light.

Substance dependence and eating disorders: impact of sequence on comorbidity.

There is a high comorbidity between eating disorders and substance dependence. The sequence of illness may indicate differences in the underlying pathology and could reflect different etiologies and treatment. The present study subjects were 218 inpatients and outpatients with diagnoses of anorexia nervosa binge-purge type (AN-BP), bulimia nervosa (BN), and eating disorder NOS (ED-NOS). Of these 218 patients, 38 had substance dependence predating the eating disorder (SDED), 71 had an eating disorder predating the substance dependence (EDSD), and 109 had only an eating disorder (ED-only). All subjects were administered the Structured Clinical Interview for DSM-III-R, Patient Edition With Psychotic Screen (SCID-P). EDSD patients had an earlier onset of the eating disorder than SDED patients and had the greatest prevalence of comorbid pathology. SDED patients were dependent on more substances. We conclude that the sequence of development of the eating disorder and substance dependence in eating disorder patients influences the amount of comorbid psychopathology. Clinical implications and future research are discussed.

More males seek treatment for eating disorders.

OBJECTIVE: This study compares males and females with DSM-IV-defined eating disorders who were admitted to the inpatient eating disorders service at The New York Hospital, Cornell between 1984 and 1987. METHODS: During this period, 51 males and 693 females presented for their first admission. Demographic information, questionnaires, and SCID interviews were used to compare the male and female samples. RESULTS: Males were significantly more likely than females to have a later onset of their eating disorder (20.56 vs. 17.15 years), and to be involved in an occupation or sport in which weight control influences performance. There were no significant gender differences in other characteristics or comorbid diagnoses. Males constituted an increasing percentage of total admissions between 1984 and 1997 (r = .692, p = .009). DISCUSSION: The similarities of core eating disorder psychopathology and comorbid illness in male and female patients encourage the continued use of similar detection and treatment strategies with both groups.

Smoking and body image concerns in adolescent girls.

OBJECTIVE: Use of cigarettes has increased dramatically among adolescent females. Because young women use smoking as a weight control strategy, increased drive for thinness and body dissatisfaction may be associated with smoking. This study examined the relationship between smoking and body image concerns among adolescent females with and without eating disorders. METHODS: Incidence of smoking and Eating Disorders Inventory (EDI) scores were compared among 411 nonclinical females and 82 eating disorder females with anorexia nervosa or bulimia nervosa aged 11 to 18. RESULTS: Of the three groups, anorectic-restrictors were the least likely and bulimics the most likely to smoke. After covarying age, both eating disorder and nonclinical smokers had significantly greater psychopathology on Drive for Thinness, Body Dissatisfaction, and Interoceptive Awareness than nonsmokers. DISCUSSION: Despite high levels of body image disturbance, anorectic-restrictors did not use smoking as a weight control strategy. Body image concerns were more prevalent in smokers than in nonsmokers.

The relationship between alexithymia, depression, and axis II psychopathology in eating disorder inpatients.

OBJECTIVE: The major purpose of this study was to examine alexithymia in relationship to depression and Axis II psychopathology in eating disorder patients. METHOD: Fifty-three female inpatients representing three DSM-IV eating disorder diagnostic groups and 14 control subjects completed the Toronto Alexithymia Scale (TAS), the Eating Disorder Inventory-2, and the Beck Depression Inventory within the first week of their hospital admission and shortly before discharge. Structured Clinical Interviews for DSM-III-R (SCID) I and II were also conducted. Multiple regression analyses were used to determine the contribution of mood, diagnostic, and personality variables in predicting the alexithymia score. RESULTS AND DISCUSSION: After controlling for depression, only the TAS factor, "difficulty expressing feelings," remained significantly different between groups, with the anorexia nervosa-restrictors (AN-R) having significantly higher scores than controls and bulimia nervosa patients. This factor appears to be a relatively stable personality characteristic in AN-R. The level of depression and the presence of avoidant personality disorder were the most predictable variables for the alexithymia total score.

A comparative analysis of Minnesota Multiphasic Personality Inventory profiles of anorexia nervosa at hospital admission, discharge, and 10-year follow-up.

The assessment of personality variables measured by the Minnesota Multiphasic Personality Inventory (MMPI), was compared in a sample of 52 female inpatients with anorexia nervosa at the time of hospitalization, discharge from hospital, and 10 years after treatment. Admission MMPI scores were significantly higher than scores both at discharge and 10 years later. There were no significant overall differences between discharge and follow-up evaluation. Discharge, but not admission, MMPI scores were positively correlated with 10-year follow-up study on seven of 10 clinical MMPI scales (all but hypochondriasis, masculinity/femininity, and hypomania). At follow-up evaluation, eating disorder poor outcome was associated with higher MMPI scores. There was no significant difference on admission MMPI scores between the four outcome groups; however, patients who recovered had a greater decrease in MMPI scores at the 10-year follow-up study compared with poor outcome patients. The long-term outcome of anorexia nervosa was largely unrelated to the severity of psychopathology during the acute phase of the illness. These results suggest that persistent personality features are best measured following treatment of acute symptomatology of anorexia nervosa.

Eating behavior and eating disorders: the interface between clinical research and clinical practice.

Cognitive-behavioral therapy (CBT) has been shown to be a highly effective form of treatment for patients with bulimia nervosa and anorexia nervosa. Issues of satiety disturbances, food restriction, and food choice are central to this form of therapy; however, ingestive behavior research that directly addresses these issues in eating disorder patients has often been overlooked by clinicians. These areas of research are reviewed and the implications of the findings for more effective CBT therapy with anorexics and bulimics are discussed.

Micro- and macroanalyses of patterns within a meal in anorexia and bulimia nervosa.

Hospitalized women with anorexia nervosa and/or bulimia nervosa and dietarily restrained and unrestrained, clinically normal women were provided with a multi-item breakfast meal. Eating patterns and hunger and satiety ratings were assessed. Subjects were offered three foods which varied in fat and carbohydrate contents. Anorectic-restrictors differed most from the control subjects: they had a longer meal duration, a slower overall rate of eating, more frequent pauses during the meal, and more short bouts of eating. They also displayed abnormal ratings of hunger and satiety: they were generally less hungry, had less urge to eat, and were more full than controls of bulimics. Both anorectic and bulimic patients showed more variability in total energy intake than did the controls. Patients usually displayed one of two patterns - either severe restriction or overeating. Abnormal hunger and satiety patterns indicating confusion typified the responses of bulimics; additionally, they showed more urge to eat in the post-meal period than did the controls. A higher proportion of fat in the initial part of the breakfast was related to a larger meal size for the bulimics. It is suggested that these techniques may be useful in evaluating the outcome of treatment for eating disorder patients.

The Yale-Brown-Cornell Eating Disorder Scale: a new scale to assess eating disorder symptomatology.

Anorectic and bulimic patients (n = 100) were interviewed using the Yale-Brown-Cornell Eating Disorder Scale (YBC-EDS). All patients reported preoccupations and rituals related to their eating disorder ranging from mild to severe symptomatology, with mean scores in the moderate range. The preoccupations were more severe than the rituals; however, the rituals were still time-consuming, distressing, and interfered with functioning. Both preoccupations and rituals were largely ego syntonic. The YBC-EDS is an easy to administer interview which characterizes and quantifies preoccupations and rituals associated with eating disorders. It is useful both for research and clinical purposes.

Anorexia nervosa and bulimia nervosa in adolescence: effects of age and menstrual status on psychological variables.

OBJECTIVE: To compare, in adolescents and adults with anorexia nervosa and bulimia nervosa, eating disorder symptomatology and comorbid affective and anxiety states. METHOD: 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. RESULTS: 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. CONCLUSION: 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.

Seasonal patterns in eating disorder subgroups.

Patients with bulimia nervosa (BN) often have seasonal patterns of mood and appetite that compare with patterns seen in seasonal affective disorder (SAD). Seasonal patterns in other eating disorder (ED) subgroups have not been adequately described. We report on seasonal patterns in mood, weight, appetite, sleep, social activity, and energy in 154 consecutive admissions to an outpatient ED program: 60 patients with anorexia nervosa (AN), 31 with BN, 34 with a history of both AN and BN (AN/BN), and 29 with an ED not otherwise specified (ED-NOS). AN patients had significantly less seasonal variation overall than either bulimic subgroup, as measured by the global seasonality score (GSS) on the Seasonal Patterns Assessment Questionnaire (SPAQ). AN patients also showed less seasonal change in mood, weight, and energy than BN patients, and less variation in mood and appetite than AN/BN patients.

Psychiatric comorbidity in patients with eating disorders.

The Structured Clinical Interview for DSM-III-R (SCID and SCID II) was administered to 105 eating disorder in-patients in order to examine rates of comorbid psychiatric disorders and the chronological sequence in which these disorders developed. Eighty-six patients, 81.9% of the sample, had Axis I diagnoses in addition to their eating disorder. Depression, anxiety and substance dependence were the most common comorbid diagnoses. Anorexic restrictors were significantly more likely than bulimics (all subtypes) to develop their eating disorder before other Axis I comorbid conditions. Personality disorders were common among the subjects; 69% met criteria for at least one personality disorder diagnosis. Of the 72 patients with personality disorders, 93% also had Axis I comorbidity. Patients with at least one personality disorder were significantly more likely to have an affective disorder or substance dependence than those with no personality disorder.

The Yale-Brown-Cornell Eating Disorder Scale: development, use, reliability and validity.

Patients with eating disorders present with a wide range of eating-related preoccupations and or rituals. Yet, eating disorder assessments traditionally have measured a finite number of specific eating-disordered thoughts or actions. The current work presents a new instrument, the Yale-Brown-Cornell Eating Disorder Scale (YBC-EDS), that does not limit assessment to a particular set of eating-related concerns or behaviors. Rather, it assesses the severity of illness associated with an individual's unique symptomatology. Reliability and validity of this new, clinician-rated instrument was tested in two independent samples of DSM-III-R eating disorder patients. The YBC-EDS eight-item scale assessing severity of preoccupations and rituals, and a set of six provisional items for assessing motivation for change were both frequently endorsed and found to have excellent interrater reliability. Internal consistency was shown to be good for the set of eight core items and the set of six items related to motivation for change. The eight-item scale demonstrated aspects of convergent validity with other assessments of eating disorder symptomatology. The set of six provisional items for assessing motivation for change was inversely related to measures to diet restriction, drive for thinness, and body dissatisfaction. This paper presents the eight-item Yale-Brown-Cornell Eating Disorder Scale for assessing illness severity in eating-disordered patients with an extensive range of symptomatology. An accompanying set of six provisional items for assessing motivation for change are also presented. Initial findings showed excellent reliability and indications of validity for both the eight-item YBC-EDS and the set of six provisional items.

Effects of depression and borderline personality traits on psychological state and eating disorder symptomatology.

The incidence of current or lifetime affective disorder and borderline personality characteristics were measured in bulimia nervosa patients. The relationship of these variables to the severity of eating disorder symptomatology (Eating Disorder Inventory [EDI]) and general psychiatric symptoms (Hopkins Symptom Checklist [SCL]) was examined. Categorical diagnostic assessments of affective disorder and borderline personality disorder (BPD) were made by Structured Clinical Interviews for DSM-III-R (SCID-I and -II). Affective disorder diagnosis (both current and lifetime) strongly influenced EDI and SCL profiles, while borderline personality characteristics had little influence. An understanding of the broad psychological symptomatology in bulimics requires the consideration of comorbid psychiatric illnesses, especially affective disorders.

Relationship of perceived macronutrient and caloric content to affective cognitions about food in eating-disordered, restrained, and unrestrained subjects.

Cognitive sets concerning food were examined in eating-disorder patients and in restrained and unrestrained control subjects. Subjects rated 38 common foods for preference, presence or absence of guilt and danger, preferred monthly frequency, and caloric, fat, and carbohydrate content. Cognitive ratings were examined based upon the individual's perceived amounts of calories and macronutrients. Hedonic ratings of foods perceived as high in fat or calories were different in patients with current or past anorexia and did not change with treatment. The fat-calorie aversions seen in these patients, therefore, appear to be stable trait characteristics of the disorder. Guilt and danger were perceived as separate constructs by unrestrained and restrained control subjects but not by patients. Perceived high amounts of calories or fat triggered stronger feelings of guilt and danger for restrained control subjects and patients (especially bulimic patients) as compared with unrestrained control subjects. The patients' expressions of guilt and danger improved with treatment.