Who seeks bariatric surgery? Psychosocial functioning among adolescent candidates, other treatment-seeking adolescents with obesity and healthy controls.

Limited data are available on the characteristics of adolescents with obesity who seek bariatric surgery. Existing data suggest that adolescent surgery candidates have a higher body mass index (BMI) than comparison adolescents with obesity, but the limited findings regarding psychosocial functioning are mixed. This study aimed to compare BMI and psychosocial functioning among adolescent bariatric surgery candidates, outpatient medical-treatment-seeking adolescents with obesity (receiving lifestyle modification), and adolescents in the normal-weight range. All adolescents completed self-report measures of impulsivity, delay discounting, depression, anxiety, stress, eating pathology, family functioning and quality of life, and had their height and weight measured. Adolescent surgical candidates had higher BMIs than both comparison groups. Surgical candidates did not differ from medical-treatment-seeking adolescents with obesity on any measure of psychosocial functioning, but both groups of adolescents with obesity reported greater anxiety and eating pathology and poorer quality of life than normal-weight adolescents. Quality of life no longer differed across groups after controlling for BMI, suggesting that it is highly related to weight status. Adolescents with obesity may experience greater anxiety, eating pathology, and quality of life impairments than their peers in the normal-weight range regardless of whether they are seeking surgery or outpatient medical treatment. Clinical implications and directions for future research are discussed.

Olanzapine versus placebo for out-patients with anorexia nervosa.

BACKGROUND: Anorexia nervosa (AN) is a serious psychiatric illness associated with significant morbidity and mortality. There is little empirical support for specific treatments and new approaches are sorely needed. This two-site study aimed to determine whether olanzapine is superior to placebo in increasing body mass index (BMI) and improving psychological symptoms in out-patients with AN. METHOD: A total of 23 individuals with AN were randomly assigned in double-blind fashion to receive olanzapine or placebo for 8 weeks together with medication management sessions that emphasized compliance. Weight, other physical assessments and measures of psychopathology were collected. RESULTS: End-of-treatment BMI, with initial BMI as a covariate, was significantly greater in the group receiving olanzapine [F(1, 20)=6.64, p=0.018]. Psychological symptoms improved in both groups, but there were no statistically significant group differences. Of the 23 participants, 17 (74%) completed the 8-week trial. Participants tolerated the medication well with sedation being the only frequent side effect and no adverse metabolic effects were noted. CONCLUSIONS: This small study suggests that olanzapine is generally well tolerated by, and may provide more benefit than placebo for out-patients with AN. Further study is indicated to determine whether olanzapine may affect psychological symptoms in addition to BMI.

Modified sham feeding of sweet solutions in women with anorexia nervosa.

Anorexia Nervosa (AN) is a disorder of self-starvation characterized by decreased meal size and food intake. While it is possible that reduced food intake in AN reflects an excess of inhibitory factors, e.g., cognitive inhibition related to fear of weight gain or abnormal postingestive negative feedback, it is also possible that decreased intake reflects diminished orosensory stimulation of food intake. This has been difficult to test directly because the amount of food ingested during a test meal by patients with AN reflects an integration of orosensory excitatory, and cognitive, learned, and postingestive inhibitory controls of eating. To begin to dissociate these controls, we adapted the modified sham feeding technique (MSF) to measure the intake of a series of sweetened solutions in the absence of postingestive stimulation. Subjects with AN (n=24) and normal controls (NC, n=10) were randomly presented with cherry Kool Aid solutions sweetened with five concentrations of aspartame (0, 0.01, 0.03, 0.08 and 0.28%) in a closed opaque container fitted with a straw. They were instructed to sip as much as they wanted of the solution during 15 1-minute trials and to spit the fluid out into another opaque container. Subjects with AN sipped less unsweetened solution than NC (p<0.05). Because this difference appeared to account completely for the smaller intakes of sweetened solutions by AN, responsiveness of intake to sweet taste per se was not different in AN and NC. Since MSF eliminated postingestive and presumably cognitive inhibitory controls, and the orosensory response to sweet taste was not different in AN than NC, we conclude that decreased intake by AN subjects under these conditions reflects the increased inhibition characteristic of this disorder that is presumably learned, with a possible contribution of decreased potency of orosensory stimulation by the sipped solutions.

Early response to antidepressant treatment in bulimia nervosa.

BACKGROUND: Bulimia nervosa (BN) is a serious psychiatric disorder characterized by frequent episodes of binge eating and inappropriate compensatory behavior. Numerous trials have found that antidepressant medications are efficacious for the treatment of BN. Early response to antidepressant treatment, in the first few weeks after medication is initiated, may provide clinically useful information about an individual's likelihood of ultimately benefitting or not responding to such treatment. The purpose of this study was to examine the relationship between initial and later response to fluoxetine, the only antidepressant medication approved by the US Food and Drug Administration (FDA) for the treatment of BN, with the goal of developing guidelines to aid clinicians in deciding when to alter the course of treatment. METHOD: Data from the two largest medication trials conducted in BN (n=785) were used. Receiver operating characteristic (ROC) curves were constructed to assess whether symptom change during the first several weeks of treatment was associated with eventual non-response to fluoxetine at the end of the trial. RESULTS: Eventual non-responders to fluoxetine could be reliably identified by the third week of treatment. CONCLUSIONS: Patients with BN who fail to report a 60% decrease in the frequency of binge eating or vomiting at week 3 are unlikely to respond to fluoxetine. As no reliable relationships between pretreatment characteristics and eventual response to pharmacotherapy have been identified for BN, early response is one of the only available indicators to guide clinical management.

Modified sham feeding of sweet solutions in women with and without bulimia nervosa.

Although it is possible that binge eating in humans is due to increased responsiveness of orosensory excitatory controls of eating, there is no direct evidence for this because food ingested during a test meal stimulates both orosensory excitatory and postingestive inhibitory controls. To overcome this problem, we adapted the modified sham feeding technique (MSF) to measure the orosensory excitatory control of intake of a series of sweetened solutions. Previously published data showed the feasibility of a "sip-and-spit" procedure in nine healthy control women using solutions flavored with cherry Kool Aid and sweetened with sucrose (0-20%). The current study extended this technique to measure the intake of artificially sweetened solutions in women with bulimia nervosa (BN) and in women with no history of eating disorders. Ten healthy women and 11 women with BN were randomly presented with cherry Kool Aid solutions sweetened with five concentrations of aspartame (0, 0.01, 0.03, 0.08 and 0.28%) in a closed opaque container fitted with a straw. They were instructed to sip as much as they wanted of the solution during 1-minute trials and to spit the fluid out into another opaque container. Across all subjects, presence of sweetener increased intake (p<0.001). Women with BN sipped 40.5-53.1% more of all solutions than controls (p=0.03 for total intake across all solutions). Self-report ratings of liking, wanting and sweetness of solutions did not differ between groups. These results support the feasibility of a MSF procedure using artificially sweetened solutions, and the hypothesis that the orosensory stimulation of MSF provokes larger intake in women with BN than controls.

The slippery slope: prediction of successful weight maintenance in anorexia nervosa.

BACKGROUND: Previous research has found that many patients with anorexia nervosa (AN) are unable to maintain normal weight after weight restoration. The objective of this study was to identify variables that predicted successful weight maintenance among weight-restored AN patients. METHOD: Ninety-three patients with AN treated at two sites (Toronto and New York) through in-patient or partial hospitalization achieved a minimally normal weight and were then randomly assigned to receive fluoxetine or placebo along with cognitive behavioral therapy (CBT) for 1 year. Clinical, demographic and psychometric variables were assessed after weight restoration prior to randomization and putative predictors of successful weight maintenance at 6 and 12 months were examined. RESULTS: The most powerful predictors of weight maintenance at 6 and 12 months following weight restoration were pre-randomization body mass index (BMI) and the rate of weight loss in the first 28 days following randomization. Higher BMI and lower rate of weight loss were associated with greater likelihood of maintaining a normal BMI at 6 and 12 months. An additional predictor of weight maintenance was site; patients in Toronto fared better than those in New York. CONCLUSIONS: This study found that the best predictors of weight maintenance in weight-restored AN patients over 6 and 12 months were the level of weight restoration at the conclusion of acute treatment and the avoidance of weight loss immediately following intensive treatment. These results suggest that outcome might be improved by achieving a higher BMI during structured treatment programs and on preventing weight loss immediately following discharge from such programs.

Toward an understanding of risk factors for anorexia nervosa: a case-control study.

BACKGROUND: Prospective, longitudinal studies of risk factors for anorexia nervosa (AN) are lacking and existing cross-sectional studies are generally narrow in focus and lack methodological rigor. Building on two studies that used the Oxford Risk Factor Interview (RFI) to establish time precedence and comprehensively assess potential risk correlates for AN, the present study advances this line of research and represents the first case-control study of risk factors for AN in the USA. METHOD: The RFI was used for retrospective assessment of a broad range of risk factors, while establishing time precedence. Using a case-control design, 50 women who met DSM-IV criteria for AN were compared to those with non-eating disorder DSM-IV psychiatric disorders (n=50) and those with no psychiatric disorder (n=50). RESULTS: Women with psychiatric disorders reported higher rates of negative affectivity, maternal and paternal parenting problems, family discord, parental mood and substance disorder, and physical and sexual abuse than women with no psychiatric disorder. Women with AN specifically reported greater severity and significantly higher rates of negative affectivity, perfectionism and family discord, and higher parental demands than women with other psychiatric disorders. The role of weight and shape concerns was most salient in the year preceding onset of AN. CONCLUSIONS: Convergent data identifying common risk factors as well as those more severe in the development of AN are emerging to inform longitudinal risk factor and prevention studies for this disorder.

Intake, sweetness and liking during modified sham feeding of sucrose solutions.

Although sweet solids and liquids are palatable to humans and ingested frequently when readily available, the quantitative relationship between sweet taste and intake has not been reported in humans. To investigate the quantitative relationship between sweet taste and intake directly, we adapted the modified sham feeding technique, previously used in humans for the study of the orosensory control of autonomic, neuroendocrine, and metabolic mechanisms, to measure the intake of solutions both unsweetened and sweetened with four concentrations of sucrose. By limiting the sucrose stimuli to the mouth, the modified sham feeding technique measures the orosensory stimulation of intake by sucrose in the absence of inhibitory postingestive stimulation. Nine healthy women were randomly presented with two series of five solutions of cherry Kool Aid unsweetened or sweetened with one of four concentrations of sucrose (2.5%, 5%, 10%, or 20%) in a closed opaque container fitted with a straw. They were instructed to sip as much as they wanted of the liquid during 2-min trials and to spit the fluid out into another opaque container. At the end of each trial, they used Visual Analogue Scales to rate the perceived intensities of sweetness and liking of the liquid that they had just sipped and spit. Intake, liking and perceived sweetness were significantly affected by sucrose concentration (p values

An open trial of an intensive summer day treatment program for severely overweight adolescents.

This open trial examined the feasibility and usefulness of treating adolescents with a body mass index (BMI) > or =95th percentile in a 6-week day treatment program within a psychiatric outpatient setting. Sixteen adolescents, ages 12-15, attended a 6-week multidisciplinary summer day treatment program. Outcome measures include pre- and post-program assessments of BMI, body fat, laboratory measures, nutritional status, physical activity, mood and eating disorder symptoms, motivation, self-esteem and quality of life. BMI, waist/hip circumferences, blood pressure, heart rate, and body fat did not change significantly from baseline to week 6. Fasting glucose decreased significantly from baseline to week 6, but there were no significant changes in other laboratory measures. The teen-rated feelings subscale of the Peds Quality of Life Scale improved. Self-esteem, as measured by the Rosenberg Self- Esteem Scale, indicated a strong trend towards improvement, and motivation measures also showed a trend for improvement. These findings suggest that a brief, intensive intervention for overweight adolescents may yield meaningful changes in quality of life, self-esteem, and motivation, even in the absence of significant weight loss.

Improved clinical status in fibromyalgia patients treated with individualized homeopathic remedies versus placebo.

OBJECTIVE: To assess the efficacy of individualized classical homeopathy in the treatment of fibromyalgia. METHODS: This study was a double-blind, randomized, parallel-group, placebo-controlled trial of homeopathy. Community-recruited persons (N = 62) with physician-confirmed fibromyalgia (mean age 49 yr, s.d. 10 yr, 94% women) were treated in a homeopathic private practice setting. Participants were randomized to receive oral daily liquid LM (1/50,000) potencies with an individually chosen homeopathic remedy or an indistinguishable placebo. Homeopathic visits involved joint interviews and concurrence on remedy selection by two experienced homeopaths, at baseline, 2 months and 4 months (prior to a subsequent optional crossover phase of the study which is reported elsewhere). Tender point count and tender point pain on examination by a medical assessor uninvolved in providing care, self-rating scales on fibromyalgia-related quality of life, pain, mood and global health at baseline and 3 months, were the primary clinical outcome measures for this report. RESULTS: Fifty-three people completed the treatment protocol. Participants on active treatment showed significantly greater improvements in tender point count and tender point pain, quality of life, global health and a trend toward less depression compared with those on placebo. CONCLUSIONS: This study replicates and extends a previous 1-month placebo-controlled crossover study in fibromyalgia that pre-screened for only one homeopathic remedy. Using a broad selection of remedies and the flexible LM dose (1/50,000 dilution factor) series, the present study demonstrated that individualized homeopathy is significantly better than placebo in lessening tender point pain and improving the quality of life and global health of persons with fibromyalgia.

Eating disorders.

Eating disorders rank among the most debilitating psychiatric disturbances that affect young women. Knowledge has increased in recent years about the two major eating disorders, anorexia nervosa (AN) and bulimia nervosa (BN); however, much remains unknown. This review article will provide an overview of the epidemiology, proposed risk factors and clinical features of AN, and BN, as well as current recommendations for evaluation and treatment of these disorders.

Serum cholesterol in bulimia nervosa.

OBJECTIVE: The purpose of this retrospective study was to replicate and to extend previous work indicating that bulimia nervosa is associated with elevated serum levels of cholesterol and to examine the association between cholesterol and other clinical and serum measures. METHODS: Clinical characteristics and laboratory data including nonfasting cholesterol and thyroid indices were collected from charts of 119 women with bulimia nervosa and 42 female controls. RESULTS: There was no significant difference between the two groups in mean age or body mass index. The mean serum cholesterol level of the patient group was statistically significantly greater than that of the control group (patients: 194 +/- 36 mg/dl; controls: 176 +/- 34 mg/dl; t = 2.77; df = 159; p =.006). The mean calculated free T4 of the bulimia nervosa patient group was statistically lower than that of the control group (patients: 1.89 +/- 0.32; controls: 2.09 +/- 0.26; t = 2.86; df = 141; p =.005). There was no correlation between calculated free T4 and serum cholesterol within the combined group (r =.04, p >.5, N = 143) or within the patient group (r =.08, p >.3, N = 118). CONCLUSIONS: The average serum level of cholesterol is elevated in the patients with bulimia nervosa. The mechanism for and the consequences of this abnormality are uncertain.

Weight gain and antipsychotic medication: differences between antipsychotic-free and treatment periods.

BACKGROUND: We performed a retrospective analysis of data involving 121 inpatients to examine the rate of weight gain during antipsychotic-free periods and during treatment with various antipsychotic drugs. METHOD: Data were analyzed to determine differences in weekly weight change during antipsychotic-free (N = 65), typical antipsychotic (N = 51), or atypical antipsychotic (N = 130) treatment periods. Atypical antipsychotic treatment periods were further subdivided into olanzapine (N = 45), clozapine (N = 47), or risperidone (N = 36) treatment periods. A paired comparison was conducted on 65 patients who had an antipsychotic-free treatment period preceding or following a neuroleptic drug treatment period. In addition, patients were classified as either non-obese (with a body mass index [BMI] < or = 29.9 kg/ml) or obese (BMI > or = 30.0 kg/m2) to test whether the rate of weight gain during treatment periods was related to initial BMI. RESULTS: Across all treatment periods, weekly weight gain was as follows: 0.89 lb/wk (0.40 kg/wk) on atypical antipsychotic medication, 0.61 lb/wk (0.27 kg/wk) on typical antipsychotic medication, and 0.21 lb/wk (0.09 kg/wk) on no antipsychotic medications. The atypical antipsychotic versus antipsychotic-free comparison was significant (F = 3.51; df = 2,231; p = .031), while the typical antipsychotic versus antipsychotic-free comparison was not. Among the individual atypical antipsychotic medications, significantly more weight gain occurred during olanzapine treatment (1.70 lb/wk) (0.76 kg/wk) than with either clozapine (0.50 lb/wk) (0.22 kg/wk) or risperidone (0.34 lb/wk) (0.15 kg/wk) treatments (F = 7.77; df = 2,117; p = .001). In the paired analysis with patients serving as their own controls, the difference between weekly weight gain during atypical antipsychotic treatment and antipsychotic-free treatment was significant (t = -3.91; df = 44; p = .001), while the difference between weight gain during typical antipsychotic treatment and antipsychotic-free treatment was not significant. With the individual drugs. treatment with both olanzapine and clozapine caused significantly higher weekly weight gain than antipsychotic-free treatment (p = .001 and p = .036, respectively). while treatment with risperidone did not. Non-obese patients (BMI < 29.9 kg/m2) and obese patients (BMI > 30.0 kg/m2) did not differ significantly in their weight gain during typical or atypical antipsychotic treatment. CONCLUSION: Treatment with atypical antipsychotics was associated with more weight gain than treatment with typical antipsychotics. Among the atypical drugs, olanzapine was associated with more weight gain than either clozapine or risperidone. The patient's admission BMI was not associated with the amount of weight gained during subsequent antipsychotic treatment.

EEG beta 1 oscillation and sucrose sensitization in fibromyalgia with chemical intolerance.

Patients with fibromyalgia (FM) have diffuse musculoskeletal pain; half report concomitant intolerance for low levels of environmental chemicals (CI). Previous investigators have hypothesized that the chronic pain and chemical intolerance reflect sensitization of different central nervous system limbic and/or mesolimbic reward pathways. We evaluated electroencephalographic (EEG) beta activity and blood glucose responses of FM patients with and without CI and normals during three repeated sucrose ingestion sessions and during a final, water-only session (testing for conditioning). The FM with CI exhibited oscillation (reversal in direction of change from session to session) at rest and then sensitization (progressive amplification) of EEG beta 1 over time across the 3 sucrose sessions versus controls. FM with CI showed sensitization of blood glucose over the 3 sucrose sessions, which, like the EEG findings, reverted toward baseline in the final water-only session. The data suggest that the subset of FM patients with CI have increased susceptibility to oscillation and physiological sensitization without conditioning, perhaps contributing to fluctuations in their chronic course.

Total energy expenditure as measured by doubly-labeled water in outpatients with bulimia nervosa.

OBJECTIVE: This study measured total energy expenditure (TEE) in symptomatic outpatient women with bulimia nervosa and normal controls. The study aimed to test the conceptual model of bulimia nervosa as an illness characterized by a physiological state of starvation, despite normal weight. METHOD: Total fat and fat-free mass were measured using hydrodensitometry and total energy expenditure was assessed via the doubly-labeled water method, in nine normal weight outpatient females with DSM-III-R bulimia nervosa and ten healthy female controls. RESULTS: Patients and controls were similar in age, body mass index, weight, lean body mass, and levels of exercise and general activity. Patients had an average baseline binge frequency of 14.7 episodes per week and purge frequency of 16.8 times per week, and had been ill for an average of 11.9 years. Group mean TEE did not differ between patients and controls (patients 2380 +/- 482 kcal/day, controls 2368 +/- 515 kcal day). Observed TEE in the bulimic subjects did not differ significantly from TEE predicted on the basis of data from the controls. DISCUSSION: This finding of normal TEE in symptomatic outpatients with bulimia nervosa is consistent with a previous study that found no difference in TEE in a sample of symptomatic inpatients with bulimia nervosa. These data suggest that the energy conserving metabolic adaptations characteristic of semi-starvation do not occur in patients with bulimia nervosa.

SLE in a United States-Mexico border community.

This report describes the results of a clinic-based study conducted to verify a community-reported excess prevalence of systemic lupus erythematosus (SLE) and a possible connection between ethnicity and environmental factors in the reporting of SLE in the United States-Mexico border town of Nogales, Arizona. A community group in Nogales reported 37 cases of SLE in its community, suggesting a prevalence rate of 200 per 100,000. This report describes 19 definite and 7 probable cases of SLE using the 1982 American College of Rheumatology criteria. All definite and probable cases were self-identified, Mexican-American females. This yields a prevalence rate of 94 per 100,000, among the highest reported to date. The majority of cases resided within 3 miles of the United States-Mexico border and within 1 mile of the polluted Nogales Wash or ground wells with documented toxins. It remains to be determined whether this confirms that SLE is more common in Mexican-Americans or whether environmental factors, especially pollutants, are predominantly responsible. In addition to the need to be aware about the apparent increased risk of SLE in many Latin-Americans, clinicians should ask about possible environmental factors.

Longitudinal relationships between childhood, adolescent, and adult eating disorders.

OBJECTIVE: This study investigates the longitudinal course of eating problems from childhood though adulthood. The following questions are answered: (1) How stable are eating disorder symptoms and diagnoses over a 17-year interval from childhood to adulthood? (2) Do early childhood eating problems predict the occurrence of eating disorders in adulthood? METHOD: An epidemiologically selected sample of approximately 800 children and their mothers received DSM-based structured psychiatric assessments in 1975, 1983, 1985, and 1992. The stability of full DSM diagnostic criteria for anorexia nervosa and bulimia nervosa, symptom scales derived from DSM criteria, and individual symptoms such as binge eating or dieting between early adolescence, late adolescence, and young adulthood was examined. RESULTS: Early adolescent bulimia nervosa is associated with a 9-fold increase in risk for late adolescent bulimia nervosa and a 20-fold increase in risk for adult bulimia nervosa. Late adolescent bulimia nervosa is associated with a 35-fold increase in risk for adult bulimia nervosa. Symptom scale scores for anorexia nervosa and bulimia nervosa correlate in the 0.3 to 0.5 range from early to late adolescence and young adulthood. For both anorexia nervosa and bulimia nervosa, gender, as well as eating symptoms at early and late adolescence, all predict young-adult eating disorder symptoms. Risk factors for the later development of eating disorders comprise eating conflicts, struggles with food, and unpleasant meals in early childhood. CONCLUSION: The presence of eating problems in early childhood or an eating disorder in adolescence confers a strong risk for an eating disorder in young adulthood.

Fluoxetine for bulimia nervosa following poor response to psychotherapy.

OBJECTIVE: This was an investigation of whether treatment with fluoxetine is useful for individuals with bulimia nervosa who do not respond to psychotherapy or relapse afterward. METHOD: Twenty-two patients with bulimia nervosa who had not responded to, or had relapsed following, a course of cognitive behavior therapy or interpersonal psychotherapy were randomly assigned to receive placebo (N=9) or fluoxetine (60 mg/day, N=13) for 8 weeks. RESULTS: The median frequency of binge eating in the previous 28 days declined from 22 to four episodes in the fluoxetine group but increased from 15 to 18 episodes in the placebo group. Similarly, purging frequency in the previous 28 days declined from 30 to six episodes in the fluoxetine group but increased from 15 to 38 episodes in the placebo group. CONCLUSIONS: Fluoxetine may be a useful intervention for patients with bulimia nervosa who have not responded adequately to psychological treatment.

Establishing guidelines for pharmacotherapy trials in bulimia nervosa and anorexia nervosa.

OBJECTIVE: This paper addresses the lack of a standard protocol for pharmacotherapy trials for patients with bulimia nervosa (BN) and anorexia nervosa (AN). METHOD: Twenty-two surveys were sent to established researchers in the field of eating disorders to elicit their opinions regarding medication trials, including baseline laboratory tests, the optimal length/frequency of medication management sessions, and the information that should or should not be included in these sessions. RESULTS: Sixteen of 22 researchers completed and returned the survey. Their answers are the basis of the data presented. DISCUSSION: We propose a battery of screening laboratory tests for both conditions. We suggest 30-45-min initial medication management sessions in both AN and BN trials with 15-min follow-ups to be held weekly for AN subjects, and weekly for 2 weeks, then biweekly for 2 weeks, then monthly, for BN subjects. We also recommend that published trials should include explicit details of medication management.

Influence of shape and weight on self-evaluation in bulimia nervosa.

OBJECTIVE: To compare three related but different measures of excessive concerns about shape and weight in bulimia nervosa (BN): influence of shape and weight (influence; DSM-IV Criterion D), overconcern with shape and weight (overconcern; DSM-III-R Criterion E), and dissatisfaction with shape and weight (dissatisfaction). METHOD: One-hundred twenty BN patients, 27 restrained eaters (RE), and 28 normal controls (NC) were assessed via the Eating Disorders Examination and self-report measures. RESULTS: Influence and overconcern, but not dissatisfaction, successfully discriminated BNs from NCs but not from REs. A minority of patients with BN obtained low scores on both influence and overconcern. However, there were few differences between those patients with low scores and those with high scores on numerous clinical characteristics. DISCUSSION: Influence and overconcern are equally valid measures of the excessive concerns about shape and weight characteristic of BN.