The relationship between affective disorder and eating disorders: a review of the literature.

The authors review the relationship between affective disorder and anorexia nervosa and bulimia across five lines of inquiry: clinical reports, psychometrics, family history, drug studies, and follow-up investigations. They conclude that affective disorder and eating disorders are related but that the nature of the relationship is unclear. After discussing possible mediating patterns, the authors propose an interactive, multidetermined understanding as the most appropriate model. They recommend that future research in this area attempt to identify subpopulations of patients with affective disorder and eating disorders by means of a longitudinal, multilevel strategy with serial determinations.

Short-term course of depressive symptoms in patients with eating disorders.

After inpatient treatment focused on aberrant eating behavior, six depressed normal-weight bulimic patients showed little improvement in depressive or eating symptoms. Four depressed anorexic patients with bulimic behavior improved in both areas, and five restricting anorexic patients had an intermediate response.

Interpretation of transference in the psychotherapy of adolescents and young adults.

There is considerable controversy in the literature surrounding the role of interpretation of transference in the expressive psychotherapy of adolescents and young adults. The authors contend that interpretation of transference is often underutilized in the psychotherapy of adolescents and that many treatments could be enriched by its inclusion. It is argued that interpretation of the transference in the immediate "here and now" of the therapeutic encounter should take precedence over genetic transference interpretation, which attempts to link current attitudes toward the therapist to archaic attitudes toward the parents. Six guidelines founded on a developmental perspective are described for exploring transference themes in this age group. While interpretation of transference is neither a panacea nor uniquely mutative with adolescents and young adults, the authors believe it has an important role to play in expressive psychotherapy if used judiciously and with foresight.

Perceptions of parental relationships in the eating disorders: the relevance of depressed mood.

Recent studies have suggested that subtypes of eating-disordered persons differ in their perceptions of their family environments. This study used Benjamin's (1983) Structural Analysis of Social Behavior to examine how depressed mood influenced eating-disordered subjects' ratings of their parental relationships. The results indicated that when level of mood disturbance was statistically controlled, there were no significant differences in parent ratings among restricting anorexics, bulimic-anorexics, bulimics, and normal control subjects. The results are discussed in terms of the possible relations of mood, eating disorder, and perception of family relationships.

Sugar, opioids and binge eating.

There is evidence that endogenous opiates are involved in the control of feeding in experimental animals. Several types of experimental obesity are associated with increased opiate production and/or increased numbers and sensitivity of opiate receptors. Research with experimental animals suggests that nutrients, particularly sugar, have an effect on feeding behavior that is mediated by opiates. For instance, the obesity-producing effect of a palatable diet in rodents is blocked by opiate antagonists. Stress induced feeding in rodents leads to preferential sucrose ingestion and is blocked by opiate antagonists and beta-endorphin. The effect of nutrients on the endogenous opiate system of humans is less clear. Clinical experience suggest that carbohydrates (sugar in particular) play a role in binge eating and obesity. Many binge eaters preferentially eat sweets during a binge. Many obese individuals consume more than half of their total daily calories as carbohydrates. Sweet snacking is a frequent behavior at times of stress. Recent evidence suggests that sugar can lead to increased beta-endorphin production in obese subjects.

Immunoreactive beta-endorphin increases after i.v. glucose in obese human subjects.

The plasma beta-endorphin of obese human subjects and non-obese controls was compared following the intravenous infusion of 25 grams of glucose. The plasma beta-endorphin of the obese subjects was significantly higher than controls one hour and four and one half hours after glucose infusion. The increased beta-endorphin of the obese subjects was associated with falling blood sugar.

Depression in bulimia at 2- to 5-year followup.

Previous research has indicated a strong association between bulimia and affective disorder at the time of initial clinical assessment. To investigate this relationship from a long-term perspective, 30 normal weight female bulimics were evaluated 2 to 5 years posthospital admission with psychometric measures and clinical interviews. Contrary to previous reports, the depression scores of the bulimics were surprisingly low, even though 26 of the 30 continued to fulfill DSM-III criteria for bulimia. Higher depression scores were associated with more intense bulimic symptomatology and attitudes, and greater psychiatric disturbance at followup. Although these data demonstrate a relationship between bulimic symptomatology and depression at long-term followup, they do not support recent assertions that bulimia is a variant of an underlying affective disorder.

Case report: high plasma level tricyclic antidepressant therapy in children: a case report and commentary.

ABSTRACT It is well known that some adults with major depression fail to respond to tricyclic antidepressants (TCA) at typical doses and plasma levels, but do respond at higher than standard levels. The literature on high-dose TCA treatment and high plasma level treatment in adults is reviewed, along with the more limited literature in children and adolescents. A case is described of a 5-year-old girl with major depression who did not respond to treatment with nortriptyline until the dose was raised to 200 mg daily (7.2 mg/kg, plasma level = 342 ng/ml). She experienced relatively minor side effects at these levels, and showed clinical deterioration when her plasma level was lowered to 188 ng/ml (160 mg/day, 5.8 mg/kg). Her high-dose and plasma level requirement was supported in an ABABA open clinical trial. High-dose, or high plasma level, treatment with tricyclic antidepressants may be a useful therapeutic option for some severely depressed children after more conventional treatments have failed. The general use of high-dose TCA treatment does not seem warranted or safe, but may be valuable for a selected subgroup of patients. Specific treatment guidelines are offered, including criteria for patient selection and monitoring for mild delirium, neurotoxic changes, seizures, electrocardiographic changes, and cardiovascular effects.

Brief psychotherapy with adolescents: individual and family approaches.

Brief psychotherapy with adolescents is a widely employed clinical procedure. In this paper key principles that inform brief individual and family therapy with adolescents have been described. The most important principle is to establish and maintain a therapeutic relationship with the teen; the second most important principle is to find a focal theme or focal point for mutual work. Many adolescents respond well to a course of brief therapy arbitrarily defined here as 20 or fewer sessions. While such an approach is not "curative," it does provide the opportunity for substantial symptom relief and improved adaptation. In selecting patients for brief therapy negative exclusion factors are more helpful than positive inclusion factors. If the teen experiences brief therapy as a positive intervention, the road is paved for his/her return if and when future problems arise. Economic pressures during the next decade will favor brief therapy over long-term therapy. The most adaptive response for therapists to this challenge is to improve their brief therapy skills. A frequently neglected skill is the ability to set modest but achievable goals in brief psychotherapy. Finding a focus for therapy lays the foundation for reasonable goal-setting.

House of Games: a cinematic study of countertransference.

In this paper we have described how examining the film House of Games can lead to an enriched understanding of the concept of countertransference for both neophyte and experienced psychotherapists. This absorbing film portrays countertransference phenomena from a number of crucial perspectives: predispositions to countertransference, direct and indirect indicators, countertransference in the "totalistic" sense as well as countertransference in the "classical" sense, parallel-process dynamics between therapy and supervision and the value of social and professional support in managing this inevitable burden. Cinema is another method, along with more traditional supervisory and didactic approaches, of assisting therapists to increase their cognitive and affective mastery of countertransference phenomena by encouraging them to analyze their emotional reactions to patients. This is no small task. In summary, we believe that the recognition, analysis and management of countertransference reactions is a necessary and life long professional task for any serious psychotherapist.

A follow-up study of thirty hospitalized bulimics.

Thirty normal-weight female bulimics were followed up 2-5 years following hospital admission using semistructured interviews and psychometric measures. Inasmuch as bulimia was only recently designated a distinct disorder, questions have emerged with regard to its clinical course and diagnostic validity. Results of this investigation suggest that bulimia displays a chronic but tractable course in that the majority of the patients continued to report bulimic behaviors at follow-up but the symptom intensity was greatly reduced from admission. The characterization of three bulimic outcome groups suggests that the outcome pattern of this disorder is heterogeneous, with some patients becoming symptom-free and others remaining severely afflicted. The durability of the symptoms and the failure of new psychiatric syndromes to emerge in the follow-up period is evidence that bulimia is a distinct diagnostic entity and not a variant of another underlying condition. The methodologic limitations of this study are addressed.

Predictive value of early testing of auditory localization for language development.

This pilot study attempted to determine whether atypical localization to voice during the first year of life could be predictive of later delayed language development. 22 children who had been tested at six to nine months of age and found to have normal hearing were retrospectively divided into "atypical' and 'normal' groups. They were then evaluated for language development at four years of age. The atypical group had significantly lower scores on two of the four measures of language competence, but the results must be interpreted with caution because of the small number of children in the study.

Five-year outcome from eating disorders: relevance of personality disorders.

In order to assess the relationship of personality disorder and eating disorder outcome 30 eating disordered patients were followed up 4-5 years after taking part in a study examining the prevalence of personality disorders in eating disordered individuals. Subjects with personality disorders did not differ from those without personality disorders in the amount of symptomatic change over time, although their psychopathology generally remained more severe. The relationship of personality disorder and clinical outcome ratings varied depending on the personality measure. SCID-II personality disorder diagnoses were not significantly associated with outcome ratings, but were related to a greater likelihood to be hospitalized and treated with psychotropic medications. Results with a new personality measure, the Wisconsin Personality Inventory, did display an association between personality disturbance and eating disorder outcome ratings and also suggested that borderline personality was a significant predictor of outcome.

Plasma immunoreactive beta-endorphin in bulimics.

The plasma beta-endorphin response to glucose ingestion was compared in 8 bulimics and 8 controls. The bulimics demonstrated a sustained elevation of plasma beta-endorphin unrelated to glucose ingestion throughout the 5-hour study period. It is hypothesized that such an elevation of beta-endorphin is the result of stress and that it may play an important role in the perpetuation of the binge-vomiting cycle.