Familial Liability for Eating Disorders and Suicide Attempts: Evidence From a Population Registry in Sweden

Diagnosed eating disorders in Danish registers - incidence, prevalence, mortality, and polygenic risk

Eating disorders are a group of severe and potentially enduring psychiatric disorders associated with increased mortality. Compared to other severe mental illnesses, they have received relatively limited research attention. Epidemiological studies often only report relative measures despite these being difficult to interpret having limited practical use. The aims of this study were to evaluate the incidence and prevalence of diagnosed anorexia nervosa (AN), bulimia nervosa, and eating disorder not otherwise specified recorded in Danish hospital registers and estimate both relative and absolute measures of subsequent mortality - both all-cause and cause-specific in a general nationwide population of 1,667,374 individuals. In a smaller, genetically informed case-cohort sample, the prediction of polygenic scores for AN, body fat percentage, and body mass index on AN prevalence and severity was estimated. Despite males being less likely to be diagnosed with an eating disorder, those that do have significantly increased rates of mortality. AN prevalence was highest for individuals with high AN and low body fat percentage/body mass index polygenic scores.

Psychometric properties of the Eating Attitudes Test-26 in Spanish schoolchildren

INTRODUCTION

Disordered Eating Attitudes and Behaviours (DEABs) can impact both the mental and physical health of children. Early detection is crucial to prevent complications and improve outcomes. The Eating Attitudes Test-26 (EAT-26) is a widely used, cost-effective tool for assessing DEABs.

OBJECTIVE

To evaluate the psychometric properties of the EAT-26 by analysing its factor structure, internal consistency, convergent validity, and measurement invariance across sexes in Spanish schoolchildren.

METHOD

Validation study in a sample of 718 schoolchildren. The sample was randomly divided into 2 groups, each with 359 participants, and we carried out an exploratory factor analysis (EFA) and a confirmatory factor analysis (CFA) of the instrument. Subsequently, we assessed the internal consistency by means of the ordinal alpha, the convergent validity with the SCOFF questionnaire and the measurement invariance across the sexes.

RESULTS

The results of the EFA and CFA supported a multidimensional structure of the EAT comprising 6 factors and 21 items. These factors underlie a second-order model of DEABs. The internal consistency was adequate for most factors. The SCOFF questionnaire showed a moderate convergent validity for most of the EAT-21 factors. We found measurement invariance across the sexes.

CONCLUSIONS

The abbreviated EAT-21 scale exhibited modest and promising psychometric properties, making it a suitable instrument for assessing DEABs in both sexes in educational settings.

Unexpected identification of obesity-associated mutations in LEP and MC4R genes in patients with anorexia nervosa

Mutations leading to a reduced or loss of function in genes of the leptin-melanocortin system confer a risk for monogenic forms of obesity. Yet, gain of function variants in the melanocortin-4-receptor (MC4R) gene predispose to a lower BMI. In individuals with reduced body weight, we thus expected mutations leading to an enhanced function in the respective genes, like leptin (LEP) and MC4R. Therefore, we have Sanger sequenced the coding regions of LEP and MC4R in 462 female patients with anorexia nervosa (AN), and 445 healthy-lean controls. In total, we have observed four and eight variants in LEP and MC4R, respectively. Previous studies showed different functional in vitro effects for the detected frameshift and non-synonymous variants: (1) LEP: reduced/loss of function (p.Val94Met), (2) MC4R: gain of function (p.Val103Ile, p.Ile251Leu), reduced or loss of function (p.Thr112Met, p.Ser127Leu, p.Leu211fsX) and without functional in vitro data (p.Val50Leut). In LEP, the variant p.Val94Met was detected in one patient with AN. For MC4R variants, one patient with AN carried the frameshift variant p.Leu211fsX. One patient with AN was heterozygous for two variants at the MC4R (p.Val103Ile and p.Ser127Leu). All other functionally relevant variants were detected in similar frequencies in patients with AN and lean individuals.

A descriptive cross-sectional study on eating disorders, suicidal thoughts, and behaviors among adolescents in the Valencian community (Spain). The pivotal role of school nurses

PURPOSE

The aims of this study were: 1) to describe the rates of risk of having an Eating Disorder (ED) and the rates of suicidal thoughts and behaviors, and 2) to examine the relationship between the risk of having an ED with suicidal thoughts and behaviors in adolescents enrolled in educational centers in the Community of Valencia (Spain).

DESIGN AND METHODS

A cross-sectional study was conducted with 718 adolescents between September 2019 and July 2020 in five schools in the Community of Valencia (Spain).

RESULTS

The adolescents studied, mostly females, are at risk of having an ED (18.6% to 30.8%) and experiencing suicidal thoughts (23% to 30.7%) and behaviors (2.2% to 6.2%). A strong association was found between EDs and suicidal thoughts and behaviors in both sexes. This association was higher in females with positive EAT-26 scores (OR: 2.09; 95% CI: 1.35-3.24) and in males with positive SCOFF scores (OR: 4.66; 95% CI: 2.40-9.02). Suicidal behaviors were positively associated with both EAT-26 (OR: 2.58; 95% CI: 1.17-5.67) and SCOFF (OR: 1.89; 95% CI: 1.21-2.26) scores in females.

CONCLUSIONS

A considerable number of adolescents, females in particular, are at risk of having an ED and of experiencing suicidal thoughts and behaviors, establishing a strong link between EDs and suicidal tendencies.

PRACTICAL IMPLICATIONS

The study highlights the importance of establishing national and regional regulations to ensure the availability of school nurses in the Community of Valencia (Spain). Collaboration between school nurses, educators, and policy makers is critical to the early detection of problems and the provision of support to both adolescents and families.

Risk of Urological Cancer Among Boys and Men Born with Hypospadias: A Swedish Population-based Study

Background

Hypospadias is a common genital malformation among boys. Studies indicate that hypospadias is associated with a higher risk of testicular cancer. Other forms of urological cancer may be linked to hypospadias via a mutual aetiology, hormonal dysfunction, or hypospadias complications, but this has not yet been studied.

Objective

To investigate the association between hypospadias and testicular cancer and the risk of other urological cancers among individuals born with hypospadias.

Design setting and participants

The study used a population-based male cohort born in Sweden in 1964-2018. Exposure was hypospadias diagnosis in national registers. Outcomes were defined using the Swedish Cancer Register. An extended cohort born from 1940 was used to study cancers among older men. Biological brothers and fathers were linked to investigate familial coaggregation.

Outcome measurements and statistical analysis

Associations were assessed using Cox proportional-hazards regression analysis, with results presented as hazard ratios.

Results and limitations

We found that hypospadias was associated with a higher risk of testicular cancer (hazard ratio 2.04, 95% confidence interval 1.42-2.92), especially for proximal hypospadias, but did not observe any clear familial coaggregation of hypospadias and testicular cancer. Hypospadias was associated with Wilms' tumour in childhood. We also found an association between hypospadias and bladder and urethral cancers, but not prostate cancer. The number of cases with hypospadias was small and the results for cancers among older men may be impacted by limitations in register coverage.

Conclusions

Our study supports the hypothesis of a higher risk of testicular cancer for men with hypospadias, especially with proximal phenotypes. Hypospadias may also be associated with a higher risk of lower urinary tract cancers, although this requires further investigation in older cohorts.

Patient summary

Boys and men in whom the opening of the urethra is not at the end of the penis (called hypospadias) at birth are at higher risk of developing testicular cancer, although their overall risk is still low. They may also have a higher risk of developing other forms of cancer in the urinary tract.

A multisite comparison using electronic health records and natural language processing to identify the association between suicidality and hospital readmission amongst patients with eating disorders

OBJECTIVES

To describe and compare the association between suicidality and subsequent readmission for patients hospitalized for eating disorder treatment, within 2 years of discharge, at two large academic medical centers in two different countries.

METHODS

Over an 8-year study window from January 2009 to March 2017, we identified all inpatient eating disorder admissions at Weill Cornell Medicine, New York, USA (WCM) and South London and Maudsley Foundation NHS Trust, London, UK (SLaM). To establish each patient's-suicidality profile, we applied two natural language processing (NLP) algorithms, independently developed at the two institutions, and detected suicidality in clinical notes documented in the first week of admission. We calculated the odds ratios (OR) for any subsequent readmission within 2 years postdischarge and determined whether this was to another eating disorder unit, other psychiatric unit, a general medical hospital admission or emergency room attendance.

RESULTS

We identified 1126 and 420 eating disorder inpatient admissions at WCM and SLaM, respectively. In the WCM cohort, evidence of above average suicidality during the first week of admission was significantly associated with an increased risk of noneating disorder-related psychiatric readmission (OR 3.48 95% CI = 2.03-5.99, p-value < .001), but a similar pattern was not observed in the SLaM cohort (OR 1.34, 95% CI = 0.75-2.37, p = .32), there was no significant increase in risk of admission. In both cohorts, personality disorder increased the risk of any psychiatric readmission within 2 years.

DISCUSSION

Patterns of increased risk of psychiatric readmission from above average suicidality detected via NLP during inpatient eating disorder admissions differed in our two patient cohorts. However, comorbid diagnoses such as personality disorder increased the risk of any psychiatric readmission across both cohorts.

PUBLIC SIGNIFICANCE

Suicidality amongst is eating disorders is an extremely common presentation and it is important we further our understanding of identifying those most at risk. This research also provides a novel study design, comparing two NLP algorithms on electronic health record data based in the United States and United Kingdom on eating disorder inpatients. Studies researching both UK and US mental health patients are sparse therefore this study provides novel data.

Risk of non-fatal self-harm and premature mortality in the three years following hospitalization in adolescents and young adults with an eating disorder: A nationwide population-based study

INTRODUCTION

Eating disorders (ED) are associated with high rates of suicide attempts and premature mortality. However, data in large samples of adolescents and young adults are limited. This study aims to assess the risk of self-harm and premature mortality in young people hospitalized with an ED.

METHODS

Individuals aged 12 to 25 years old hospitalized in 2013-2014 in France with anorexia nervosa and/or bulimia nervosa as a primary or associated diagnosis were identified from French national health records. They were compared to two control groups with no mental disorders, and with any other mental disorder than ED. The main outcomes were any hospitalization for deliberate self-harm and mortality in the 3 years following hospitalization. Logistic regression models were used.

RESULTS

This study included 5, 452 patients hospitalized with an ED, 14,967 controls with no mental disorder, and 14,242 controls with a mental disorder other than an ED. During the three-year follow-up, 13.0% were hospitalized for deliberate self-harm (vs. 0.2 and 22.0%, respectively) and 0.8% died (vs. 0.03 and 0.4%). After adjustment, hospitalization with an ED was associated with more self-harm hospitalizations (hazard ratio [HR] = 46.0, 95% confidence interval [32.3-65.3]) and higher all-cause mortality (HR = 12.6 [4.3-37.3]) relative to youths without any mental disorder; less self-harm hospitalizations (HR = 0.5 [0.5-0.6]) but higher mortality (HR = 1.6 [1.0-2.4]) when compared to youths with any other mental disorder.

CONCLUSION

Young patients hospitalized with an ED are at high risk of self-harm and premature mortality. It is urgent to evaluate and implement the best strategies for post-discharge care and follow-up.

PUBLIC SIGNIFICANCE

We found that the risk of being hospitalized for a suicide attempt is 46 times higher and mortality 13 times higher than the general population in adolescents and young adults during the 3 years following hospitalization with an eating disorder. Eating disorders are also associated with a 1.5 higher risk of premature mortality relative to other mental disorders. This risk is particularly high in the 6 months following hospitalization. It is therefore crucial to implement careful post-discharge follow-up in patients hospitalized for eating disorders.

Factors associated with lifetime history of eating disorder in non-psychotic patients with suicidal ideation

BACKGROUND

Data on the sociodemographic, biographical, and clinical factors associated with a lifetime diagnosis of eating disorders (ED) in patients with non-psychotic mental disorders (NPMD) and suicidal ideation (SI) are scarce.

METHODS

A cohort study was conducted at the Moscow Research and Clinical Center for Neuropsychiatry. The sample consisted of consecutive patients with non-psychotic mental disorders and SI, aged 1845 years. Participants with a lifetime diagnosis of anorexia and/or bulimia (then in remission or recovery) were compared with those without ED in terms of their sociodemographic profile, clinical characteristics, lifetime traumatic events, and some behavioral patterns. All participants underwent the Russian version of the Self-Injurious Thoughts and Behaviors Interview and completed the Brief Reasons for Living Inventory, the State and Trait Anxiety Inventory, and the Beck Depression Inventory.

RESULTS

A total of 892 patients with non-psychotic mental disorders and SI were included in the study. The mean age was 25.7 years, and 84% were assigned female at birth. Same-sex experience was more common in the ED group. Patients with an ED were more likely to have a history of physical and sexual abuse and to have witnessed domestic violence. The proportion of participants with piercings, tattoos, or severe body modifications was significantly higher in the ED group. Patients with a lifetime ED were more likely to engage in nonsuicidal self-injurious behaviors and to have a history of suicide attempts.

CONCLUSION

Lifetime ED in NPMD patients with SI is associated with younger age, being assigned female at birth, having an alternative gender identity, having same-sex experience, having more than one psychiatric diagnosis, having been diagnosed with bipolar disorder, experiencing severe depression and anxiety, being exposed to multiple traumatic experiences, having various body modifications, practicing NSSI, and having a lifetime story of suicide attempts.

Suicidal behavior across a broad range of psychiatric disorders

Suicide is a leading cause of death worldwide. In 2020, some 12.2 million Americans seriously contemplated suicide, 3.2 million planned suicide attempts, and 1.2 million attempted suicide. Traditionally, the approach to treating suicidal behavior (SB) has been to treat the "underlying" psychiatric disorder. However, the number of diagnoses associated with SB is considerable. We could find no studies describing the range of disorders reported to be comorbid with SB. This narrative review summarizes literature documenting the occurrence of SB across the lifespan and the full range of psychiatric diagnoses, not only BPD and those that comprise MDE, It also describes the relevance of these observations to clinical practice, research, and nosology. The literature searches contained the terms "suicid*" and each individual psychiatric diagnosis and identified 587 studies. We did not include case reports, case series, studies only addressing suicidal ideation or non-suicidal self-injury (NSSI), studies on self-harm, not distinguishing between SB and NSSI and studies that did not include any individuals that met criteria for a specific DSM-5 diagnosis (n = 366). We found that SB (suicide and/or suicide attempt) was reported to be associated with 72 out of 145 diagnoses, although data quality varied. Thus, SB is not exclusively germane to Major Depressive Episode (MDE) and Borderline Personality Disorder (BPD), the only conditions for which it is a diagnostic criterion. That SB co-occurs with so many diagnoses reinforces the need to assess current and past SB regardless of diagnosis, and supports the addition of charting codes to the DSM-5 to indicate current or past SB. It also comports with new data that specific genes are associated with SB independent of psychiatric diagnoses, and suggests that SB should be managed with specific suicide prevention interventions in addition to treatments indicated for co-occurring diagnoses. SB diagnostic codes would help researchers and clinicians document and measure SB's trajectory and response to treatment over time, and, ultimately, help develop secondary and tertiary prevention strategies. As a separate diagnosis, SB would preclude situations in which a potentially life-threatening behavior is not accounted for by a diagnosis, a problem that is particularly salient when no mental disorder is present, as is sometimes the case.

Non-suicidal self-injury, suicidal thoughts and behaviors in individuals with an eating disorder relative to healthy and psychiatric controls: A systematic review and meta-analysis

OBJECTIVE

Eating disorders (ED) may be associated with an increased prevalence of non-suicidal self-injury (NSSI) and suicidal thoughts and behaviors (STBs) relative to healthy (HC) and psychiatric (PC) controls. However, precise estimates of differences in prevalence between individuals with EDs and controls are unclear. We compared the prevalence of NSSI, suicidal ideation (SI), suicide attempts (SA), and deaths by suicide in controls and individuals with EDs.

METHOD

We searched MEDLINE, PsycINFO, EMBASE, and CINAHL for peer-reviewed publications reporting the prevalence of NSSI and/or STBs in EDs and HC or PC group (PROSPERO: CRD42021286754). A series of random-effects meta-analyses were conducted to estimate pooled odds ratios (ORs) for NSSI, SI, SA, and death by suicide in EDs.

RESULTS

Across 32 studies, individuals with an ED had a significantly increased prevalence of NSSI (HC: OR = 6.85 [95% CI: 3.60, 13.04]; PC: OR = 2.74 [95% CI: 1.49, 5.06]), SI (HC: OR = 3.63 [95% CI: 2.43, 5.41]; PC: OR = 3.10 [95% CI: 2.01, 4.78]), and SA (HC: OR = 5.16 [95% CI: 4.27, 6.24]; PC: OR = 1.37 [95% CI: 0.37, 4.99]) relative to HC and PC groups. A 2.93-times increased odd of death by suicide did not achieve statistical significance. There was a high-level of heterogeneity between studies.

DISCUSSION

Our findings indicate that ED populations have an increased prevalence of NSSI, SI, and SA but not death by suicide compared to controls and emphasize the need for effective clinical strategies to address these behaviors in ED populations.

PUBLIC SIGNIFICANCE

This review provides evidence for an increased prevalence of non-suicidal self-injury, suicidal ideation, and suicide attempts in populations with eating disorders compared to controls. Our findings emphasize the need for effective clinical strategies to address these behaviors in patients with eating disorders.

Adolescents with anorexia nervosa or atypical anorexia nervosa with premorbid overweight/obesity: What should we do about their weight loss?

Traditionally, anorexia nervosa (AN) was understood to exist exclusively among underweight individuals and weight was used to assess level of severity and course of treatment. Recent trends have found a growing number of individuals presenting with AN or atypical AN (AAN) (i.e., those who remain with weight in a "normal" or "healthy" range despite significant weight loss) have a premorbid history of overweight/obesity. Individuals with AN/AAN and premorbid overweight/obesity represent an especially metabolically vulnerable population as with either AN or AAN, there is marked weight loss. Patients with AAN present a specific challenge as healthcare professionals must identify a clinically significant eating disorder in adolescents of potentially "normal" weights and then must balance their knowledge and training of traditional treatment of AN with obesity treatment and prevention. Currently, there are no evidence-based treatments to guide medical and mental health professionals regarding weight restoration, medical stabilization, and psychological treatment in patients with AN/AAN with a history of overweight/obesity while also addressing risk prevention for obesity.

Comparison of the burden of anorexia nervosa in the Middle East and North Africa region between 1990 and 2019

BACKGROUND

Anorexia nervosa (AN) is a complex and heritable psychiatric disorder, which imposes significant mortality and morbidity on sufferers globally. We aimed to report the prevalence, incidence and disability-adjusted life-years (DALYs) attributable to AN in the Middle East and North Africa (MENA) region by age, sex and socio-demographic index (SDI), between 1990 and 2019.

METHODS

The disease burden attributable to AN was obtained for the 21 countries located in the MENA region between 1990 and 2019 using publicly available data from the Global Burden of Disease (GBD) 2019 study. All estimates were provided as counts and age-standardized rates per 100,000 population, along with 95% uncertainty intervals (UIs).

RESULTS

In 2019, the estimated age-standardised point prevalence and incidence rate of AN (per 100,000) in MENA were 49.3 (95% UI: 34.6-70.4) and 16.0 (11.3-22.0), which were 11.4% (7.3-15.4) and 5.9% (2.6-9.1) higher than in 1990, respectively. Furthermore, the regional age-standardised DALY rate was 10.6 (6.3-17.0) per 100,000 in 2019, which was 11.8% (5.2-19.1) higher than in 1990. In 2019, Kuwait [17.3 (10.3-27.9)] and Afghanistan [6.3 (3.7-10.3)] had the highest and lowest age-standardised DALY rates, respectively. In addition, Iran showed the largest increases in the age-standardised point prevalence [30.0% (24.1-36.2)], incidence [24.6% (18.6-30.4)] and DALY [30.5% (22.6-38.9)] rates between 1990 and 2019. In 2019, the number of prevalent cases and prevalence estimates peaked in the 15-19 age group for males and the 20-24 age group for females, with females having a higher number of cases and prevalence in all age groups. In 2019, the age-standardised DALY rates in MENA were higher than the global rates among males aged 10-34 years, but were lower than the global estimates among females in almost all age groups. In addition, the burden of AN was positively associated with the level of socio-economic development during the measurement period.

CONCLUSIONS

The burden of AN in the MENA region increased between 1990 and 2019, which indicates that it is likely to become a more serious public health issue in the future. Up-to-date information about the epidemiological trends in the region would allow health policymakers to make informed and appropriate decisions to help address this issue. The findings of the present study showed that the point prevalence and incidence rate of anorexia nervosa have increased in the Middle East and North Africa region between 1990 and 2019. The highest burden in 2019 was found in Kuwait, while Afghanistan had the lowest attributable burden. In addition, between 1990 and 2019 Iran had the largest increase in the point prevalence of anorexia nervosa. Also in 2019, anorexia nervosa was more prevalent in females and peaked in the 15-19 age group for males and the 20-24 age group for females. Furthermore, as the level of socioeconomic development increased, so did the burden attributable to anorexia nervosa.

The Follow-Up of Eating Disorders from Adolescence to Early Adulthood: A Systematic Review

Eating disorders (EDs) are common among children and adolescents and are characterized by excessive concerns for physical appearance, distorted body image, and fear of gaining weight. The purpose of this review is to evaluate the follow-up of EDs from adolescence to adulthood, analyzing persistence, relapses, and associated comorbidities. We searched scientific articles in PubMed, PsycInfo, Scopus, and Embase through two research strings, one for quantitative outcomes (recovery/persistence, relapse, and remission) and one for the other outcomes (psychiatric and medical comorbidities, substance use, and social-relational complications). From a total of 8043 retrieved articles, we selected 503 papers after exclusion of duplicates and title/abstract screening. After a full-text evaluation, we included 16 studies eligible for this review. We performed a meta-analysis describing the quantitative results, and we created a narrative synthesis for the qualitative outcomes. Results: Our results confirm that EDs can persist in early adulthood in 40.7% of cases with a relapse percentage of 24.5%. Individuals with an ED more frequently present with an empathy deficit and comorbid anxiety and depressive disorders. EDs are chronic and complex disorders, more frequent in females. In most cases, EDs reduce the autonomy of individuals who present many difficulties in affirming their independence from parental family.

Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature

BACKGROUND

Eating disorders (EDs) are potentially severe, complex, and life-threatening illnesses. The mortality rate of EDs is significantly elevated compared to other psychiatric conditions, primarily due to medical complications and suicide. The current rapid review aimed to summarise the literature and identify gaps in knowledge relating to any psychiatric and medical comorbidities of eating disorders.

METHODS

This paper forms part of a rapid review) series scoping the evidence base for the field of EDs, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for English-language studies focused on the psychiatric and medical comorbidities of EDs, published between 2009 and 2021. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised.

RESULTS

A total of 202 studies were included in this review, with 58% pertaining to psychiatric comorbidities and 42% to medical comorbidities. For EDs in general, the most prevalent psychiatric comorbidities were anxiety (up to 62%), mood (up to 54%) and substance use and post-traumatic stress disorders (similar comorbidity rates up to 27%). The review also noted associations between specific EDs and non-suicidal self-injury, personality disorders, and neurodevelopmental disorders. EDs were complicated by medical comorbidities across the neuroendocrine, skeletal, nutritional, gastrointestinal, dental, and reproductive systems. Medical comorbidities can precede, occur alongside or emerge as a complication of the ED.

CONCLUSIONS

This review provides a thorough overview of the comorbid psychiatric and medical conditions co-occurring with EDs. High psychiatric and medical comorbidity rates were observed in people with EDs, with comorbidities contributing to increased ED symptom severity, maintenance of some ED behaviours, and poorer functioning as well as treatment outcomes. Early identification and management of psychiatric and medical comorbidities in people with an ED may improve response to treatment and overall outcomes.

Genetics and neurobiology of eating disorders

Eating disorders (anorexia nervosa, bulimia nervosa and binge-eating disorder) are a heterogeneous class of complex illnesses marked by weight and appetite dysregulation coupled with distinctive behavioral and psychological features. Our understanding of their genetics and neurobiology is evolving thanks to global cooperation on genome-wide association studies, neuroimaging, and animal models. Until now, however, these approaches have advanced the field in parallel, with inadequate cross-talk. This review covers overlapping advances in these key domains and encourages greater integration of hypotheses and findings to create a more unified science of eating disorders. We highlight ongoing and future work designed to identify implicated biological pathways that will inform staging models based on biology as well as targeted prevention and tailored intervention, and will galvanize interest in the development of pharmacologic agents that target the core biology of the illnesses, for which we currently have few effective pharmacotherapeutics.

The role of early-life family composition and parental socio-economic status as risk factors for obsessive-compulsive disorder in a Danish national cohort

Research on early-life family environment on obsessive-compulsive disorder (OCD) risk is limited, and sex differences have not been sufficiently studied. We investigated early-life family composition and parental socio-economic status (SES) as OCD risk factors while stratifying for sex in a sample of 1,154,067 individuals from the Danish population (7550 of whom had OCD). Data on early-life family composition (birth order, number of siblings, number of parents in household at proband age 6), parental SES at age 6 (parental income, occupation, and education level), history of parental psychiatric illness, and parental age at birth on OCD risk (i.e., an ICD-10 diagnosis of F42.x) were obtained from Danish population registers. Survival analyses using Cox regression were performed with age as the underlying time variable. Analyses were adjusted for calendar time, and differential effect by sex was tested for exposures. We found that birth order and advanced maternal age were risk factors for OCD in males, and being an only child was associated with increased OCD risk in both sexes. Early childhood SES variables including parental education, occupation, and income were associated with OCD risk, and these effects were more pronounced in females. Significant interaction effects for parental education/occupation and the presence of non-OCD psychiatric diagnoses in the proband also emerged. Our results suggest that early-life SES and family composition may be important risk factors for OCD, and heterogeneity in OCD cases in terms of psychiatric comorbidities, as well as sex differences should be carefully examined in relation to risk factors.

Expressive suppression a mediating variable between stress and procrastination in eating behavior disorder

Eating disorders (EDs) are psychiatric illnesses in which emotions play an important role in their development and maintenance. These disorders are associated with expressive suppression, stress, and procrastination. The purpose of this work was to explain eating disorders from stress and procrastination, with expressive suppression as a mediating variable. It was attended by 918 students from three universities in Ecuador. The information was collected through four instruments: inventory of eating disorders, perceived stress scale, Tuckman procrastination scale and emotional regulation questionnaire. The data was analyzed through a mediational analysis in the Jasp program, version 15. The independent variables were: procrastination and stress, the dependent variable was risk of experiencing bulimia (REB) and the mediating variable was expressive suppression. Procrastination and stress, mediated by expressive suppression, were found to have no statistically significant effect on EBR. Procrastination has a direct effect on REB, although stress does not, and the model between expressive suppression and REB explains a good percentage of the variance.

Resilience Is Associated with Less Eating Disorder Symptoms in the NutriNet-Santé Cohort Study

Resilience is a positive psychological trait associated with a lower risk of some physical and mental chronic diseases and could be an important protective factor against eating disorders (EDs). The aim of this study was to assess cross-sectional and longitudinal associations between resilience and ED in a large cohort of French adults. In 2017, a total of 25,000 adults from the NutriNet-Santé cohort completed the Brief Resilience Scale (BRS). ED symptoms were measured in 2017 and 2020, with the Sick-Control-One-Fat-Food (SCOFF) questionnaire. Cross-sectional and longitudinal associations between resilience and EDs were analyzed using logistic regression, controlling for sociodemographic and lifestyle characteristics. Cross-sectional analyses showed that more resilient participants exhibited EDs less frequently than did less resilient participants (p < 0.0001). Longitudinal analyses showed that, during the three years of follow up, higher resilience was negatively associated with incident EDs (OR: 0.67, 95%CI: 0.61–0.74), persistent EDs (0.46 (0.42–0.51)), and intermittent EDs (0.66 (0.62–0.71)), compared with no ED. More resilient participants were also less likely to have a persistent ED than to recover from EDs (0.73 (0.65–0.82)). This study showed that resilience was associated with less ED symptoms and a higher chance of recovery.

Using natural language processing to extract self-harm and suicidality data from a clinical sample of patients with eating disorders: a retrospective cohort study

OBJECTIVES

The objective of this study was to determine risk factors for those diagnosed with eating disorders who report self-harm and suicidality.

DESIGN AND SETTING

This study was a retrospective cohort study within a secondary mental health service, South London and Maudsley National Health Service Trust.

PARTICIPANTS

All diagnosed with an F50 diagnosis of eating disorder from January 2009 to September 2019 were included.

INTERVENTION AND MEASURES

Electronic health records (EHRs) for these patients were extracted and two natural language processing tools were used to determine documentation of self-harm and suicidality in their clinical notes. These tools were validated manually for attribute agreement scores within this study.

RESULTS

The attribute agreements for precision of positive mentions of self-harm were 0.96 and for suicidality were 0.80; this demonstrates a 'near perfect' and 'strong' agreement and highlights the reliability of the tools in identifying the EHRs reporting self-harm or suicidality. There were 7434 patients with EHRs available and diagnosed with eating disorders included in the study from the dates January 2007 to September 2019. Of these, 4591 (61.8%) had a mention of self-harm within their records and 4764 (64.0%) had a mention of suicidality; 3899 (52.4%) had mentions of both. Patients reporting either self-harm or suicidality were more likely to have a diagnosis of anorexia nervosa (AN) (self-harm, AN OR=3.44, 95% CI 1.05 to 11.3, p=0.04; suicidality, AN OR=8.20, 95% CI 2.17 to 30.1; p=0.002). They were also more likely to have a diagnosis of borderline personality disorder (p≤0.001), bipolar disorder (p<0.001) or substance misuse disorder (p<0.001).

CONCLUSION

A high percentage of patients (>60%) diagnosed with eating disorders report either self-harm or suicidal thoughts. Relative to other eating disorders, those diagnosed with AN were more likely to report either self-harm or suicidal thoughts. Psychiatric comorbidity, in particular borderline personality disorder and substance misuse, was also associated with an increase risk in self-harm and suicidality. Therefore, risk assessment among patients diagnosed with eating disorders is crucial.

Self-harm hospitalization following bariatric surgery in adolescents and young adults

BACKGROUND

While bariatric surgery has demonstrated physical and psychological benefits, a risk of suicide and non-fatal self-harm has also been shown. The aim of this study was to compared the rate of hospitalization for self-harm during a three-year observational follow-up period between adolescents/young adults who underwent bariatric surgery in France in 2013-2014 and two control groups.

METHODS

All individuals aged 12-25 years old who underwent bariatric surgery in France between January 1st, 2013, and December 31st, 2014, were identified with a validated algorithm from the French national hospital database, and compared to a healthy sample of the general population matched for age and gender. Information relative to hospitalizations, including for self-harm (ICD-10 codes X60-84), were extracted i) between 2008 and the surgery, and ii) for a three-year follow-up period. A second unmatched control group with obesity but no bariatric surgery was also identified. Survival analyses with adjustments for confounding variables were used.

RESULTS

In 2013-2014, 1984 youths had bariatric surgery in France. During follow-up, 1.5% were hospitalized for self-harm vs. 0.3% for controls (p < 0.0001). After adjustment, subsequent hospitalization for self-harm was associated with bariatric surgery (HR 3.64, 95% CI 1.70-7.81), prior psychiatric disorders (HR 7.76, 95% CI 3.76-16.01), and prior self-harm (HR 4.43, 95% CI 1.75-11.24). When compared to non-operated youths with obesity, bariatric surgery was not associated with self-harm while prior mental disorders and self-harm were. Mortality reached 0.3% after surgery.

CONCLUSIONS

Bariatric surgery is associated with an increased risk of self-harm, mainly in relation to preexisting psychological conditions. Vigilance and appropriate care are thus warranted in vulnerable individuals.

The Association of Body Image Self-Discrepancy With Female Gender, Calorie-Restricted Diet, and Psychological Symptoms Among Healthy Junior High School Students in Japan

Background: Body image self-discrepancy reflects a preference for weight loss regardless of normal body size and is a distorted cognition that may be a precursor to eating disorders. The aim of this study was to investigate factors associated with body image self-discrepancy among healthy junior high school students in Japan.

Method: This cross-sectional study was conducted at one junior high school in Saitama, Japan, in December 2016. After excluding obese participants (defined as 20% above their ideal weight), 304 students (mean age, 13.9years; n=181 girls, 59.5%) who fell into underweight (n=22, 7.2%) and normal weight categories were selected. Body image self-discrepancy was measured using the Contour Drawing Rating Scale which includes eight separate figures representing body sizes. We then calculated the difference by subtracting ideal from current body sizes and defined body image self-discrepancy if the difference >1.

Results: Girls constituted 92% (n=49) of the 53 students with body image self-discrepancy. In all students, multivariable stepwise models demonstrated that female gender (OR, 6.92, 95% CI: 2.33–20.51), a calorie-restricted diet (OR, 5.18, 95% CI: 2.22–12.05), and psychological symptoms (OR, 1.47, 95% CI: 1.15–1.87) were significantly associated with an increased risk of body image self-discrepancy. Specifically for girls, an increased risk of body image self-discrepancy was associated with calorie-restricted suppers and psychological symptoms.

Conclusion: Body image self-discrepancy among healthy adolescents in Japan was found to be closely linked to being a girl, having a calorie-restricted diet, and having psychological symptoms.

Reframing anorexia nervosa as a metabo-psychiatric disorder

Anorexia nervosa (AN) is a serious and often fatal illness. Despite decades of research, investigators have failed to adequately advance our understanding of the biological aspects of AN that could inform the development of effective interventions. Genome-wide association studies are revealing the important role of metabolic factors in AN, and studies of the gastrointestinal tract are shedding light on disruptions in enteric microbial communities and anomalies in gut morphology. In this opinion piece, we review the state of the science through the lens of the clinical presentation of illness. We project how the integration of rigorous science in genomics and microbiology, in collaboration with experienced clinicians, has the potential to markedly enhance treatment outcome via precision interventions.

Familial co-aggregation of schizophrenia and eating disorders in Sweden and Denmark

Eating disorders and schizophrenia are both moderately to highly heritable and share significant genetic risk despite distinct diagnostic criteria. Large-scale family studies on the co-aggregation of these disorders are lacking. Thus, we aimed to estimate the co-occurrence and familial co-aggregation of these disorders within the entire Swedish and Danish population. The proband cohort consisted of individuals born in Sweden (1977-2003) and Denmark (1984-2006) and still residing in their respective country at age six (N_Sweden = 2,535,191, N_Denmark = 1,382,367). Probands were linked to their biological parents, siblings, grandparents, uncles/aunts, and cousins. Diagnoses for anorexia nervosa (AN) and other eating disorders (OED: bulimia nervosa, binge-eating disorder, and eating disorder not otherwise specified) for probands and schizophrenia diagnoses for both probands and relatives were obtained. The likelihood of having schizophrenia in those with AN or OED and their relatives was compared with individuals without eating disorder diagnoses and their relatives. Probands with AN or OED were more likely to have schizophrenia than probands without these disorders. All relatives of probands with AN or OED (except parents and uncles/aunts of probands with AN) were at increased risk of schizophrenia. In general, the magnitude of odds ratios attenuated with decreasing genetic relatedness. These results suggest familial liability contributes to the association between eating disorders and schizophrenia. Clinicians should be mindful of this comorbid and co-aggregation pattern as it may influence case conceptualization and treatment decisions.

The Association of Malnutrition, illness duration, and pre-morbid weight status with anxiety and depression symptoms in adolescents and young adults with restrictive eating disorders: a cross-sectional study

BACKGROUND

Restrictive eating disorders (EDs) are often comorbid with anxiety and depression symptoms, placing patients at risk for more severe disease, worse treatment outcomes, and higher rates of mortality. To identify risks for developing such co-morbidities, we assessed the association of malnutrition, ED illness duration, and pre-morbid weight status with symptoms of anxiety and depression in adolescents/young adults (AYAs) with EDs.

METHODS

145 participants with restrictive EDs (anorexia nervosa [AN], other specified feeding and eating disorders [OSFED], avoidant restrictive food intake disorder [ARFID]) were included from the RECOVERY study, a longitudinal web-based registry of AYAs with EDs. We measured malnutrition as percent of expected body mass index (%eBMI), based on participants' pre-morbid growth trajectory. Outcomes were anxiety and depression scores from the Generalized Anxiety Disorder 7-item (GAD-7) and Center for Epidemiologic Studies Depression (CES-D) scales. We used multiple linear regression to examine the association of malnutrition, ED duration, and pre-morbid weight status with symptoms of anxiety and depression.

RESULTS

Mean (SD) age was 16.4(3.0) years; 87% were female; 89% white; 85% had AN, 6% OSFED, 10% ARFID. Of these, 2/3 had ED symptoms ≥1 year, 1/3 had previous higher level of ED care (HLOC), and half were taking psychiatric medications. Mean %eBMI was 90% (range 57-112%). Mean GAD-7 was 9.4(5.9) and CES-D was 24(13.8), indicating most participants had clinically significant anxiety and/or depression. Degree of malnutrition was not significantly associated with anxiety or depression adjusting for age, sex, sexual orientation, ED diagnosis, and use of psychiatric medication. Those with longer duration of ED symptoms had higher depression scores after adjusting for malnutrition, HLOC, length of ED symptoms, and time in our care (p = 0.038). Patients with pre-morbid BMIs ≥75th percentile had lower depression scores than those with pre-morbid BMIs <75th percentile (p = 0.014).

CONCLUSIONS

We find high degree of clinically relevant anxiety and depression symptoms in a population of AYAs with EDs. Our findings suggest that factors beyond malnutrition play a role in the co-morbid mood and anxiety disorders in this population. Overall, rapid ED diagnosis and comprehensive treatment for patients with EDs across the weight spectrum-and especially those with psychiatric co-morbidities-will likely aid in recovery.

Association and Familial Coaggregation of Type 1 Diabetes and Eating Disorders: A Register-Based Cohort Study in Denmark and Sweden

OBJECTIVE

To ascertain the association and coaggregation of eating disorders and childhood-onset type 1 diabetes in families.

RESEARCH DESIGN AND METHODS

Using population samples from national registers in Sweden (n = 2,517,277) and Demark (n = 1,825,920), we investigated the within-individual association between type 1 diabetes and eating disorders and their familial coaggregation among full siblings, half siblings, full cousins, and half cousins. On the basis of clinical diagnoses, we classified eating disorders into any eating disorder (AED), anorexia nervosa (AN) and atypical AN, and other eating disorder (OED). Associations were determined with hazard ratios (HRs) with 95% CIs from Cox regressions.

RESULTS

Swedish and Danish individuals with a type 1 diabetes diagnosis had a greater risk of receiving an eating disorder diagnosis (HR [95% CI] Sweden: AED 2.02 [1.80-2.27], AN 1.63 [1.36-1.96], OED 2.34 [2.07-2.63]; Denmark: AED 2.19 [1.84-2.61], AN 1.78 [1.36-2.33], OED 2.65 [2.20-3.21]). We also meta-analyzed the results: AED 2.07 (1.88-2.28), AN 1.68 (1.44-1.95), OED 2.44 (2.17-2.72). There was an increased risk of receiving an eating disorder diagnosis in full siblings in the Swedish cohort (AED 1.25 [1.07-1.46], AN 1.28 [1.04-1.57], OED 1.28 [1.07-1.52]); these results were nonsignificant in the Danish cohort.

CONCLUSIONS

Patients with type 1 diabetes are at a higher risk of subsequent eating disorders; however, there is conflicting support for the relationship between having a sibling with type 1 diabetes and an eating disorder diagnosis. Diabetes health care teams should be vigilant about disordered eating behaviors in children and adolescents with type 1 diabetes.

Association of etiological factors across the extreme end and continuous variation in disordered eating in female Swedish twins

BACKGROUND

Accumulating evidence suggests that many psychiatric disorders etiologically represent the extreme end of dimensionally distributed features rather than distinct entities. The extent to which this applies to eating disorders (EDs) is unknown.

METHODS

We investigated if there is similar etiology in (a) the continuous distribution of the Eating Disorder Inventory-2 (EDI-2), (b) the extremes of EDI-2 score, and (c) registered ED diagnoses, in 1481 female twin pairs at age 18 years (born 1992-1999). EDI-2 scores were self-reported at age 18. ED diagnoses were identified through the Swedish National Patient Register, parent-reported treatment and/or self-reported purging behavior of a frequency and duration consistent with DSM-IV criteria. We differentiated between anorexia nervosa (AN) and other EDs.

RESULTS

The heritability of the EDI-2 score was 0.65 (95% CI 0.61-0.68). The group heritabilities in DeFries-Fulker extremes analyses were consistent over different percentile-based extreme groups [0.59 (95% CI 0.37-0.81) to 0.65 (95% CI 0.55-0.75)]. Similarly, the heritabilities in liability threshold models were consistent over different levels of severity. In joint categorical-continuous models, the twin-based genetic correlation was 0.52 (95% CI 0.39-0.65) between EDI-2 score and diagnoses of other EDs, and 0.26 (95% CI 0.08-0.42) between EDI-2 score and diagnoses of AN. The non-shared environmental correlations were 0.52 (95% CI 0.32-0.70) and 0.60 (95% CI 0.38-0.79), respectively.

CONCLUSIONS

Our findings suggest that some EDs can partly be conceptualized as the extreme manifestation of continuously distributed ED features. AN, however, might be more distinctly genetically demarcated from ED features in the general population than other EDs.

Genetic and environmental sources of familial coaggregation of obsessive-compulsive disorder and suicidal behavior: a population-based birth cohort and family study

Obsessive-compulsive disorder (OCD) is associated with high risk of suicide. It is yet unknown whether OCD and suicidal behaviors coaggregate in families and, if so, what are the mechanisms underlying this coaggregation. In a population-based birth cohort and family study, we linked individuals born in Sweden in 1967-2003 (n = 3,594,181) to their parents, siblings, and cousins, and collected register-based diagnoses of OCD, suicide attempts, and deaths by suicide and followed them until December 31, 2013. We also applied quantitative genetic modeling to estimate the contribution of genetic and environmental factors to the familial coaggregation of OCD and suicidal behavior. An elevated risk of suicide attempts was observed across all relatives of individuals with OCD, increasing proportionally to the degree of genetic relatedness, with odds ratios (OR) ranging from 1.56 (95% confidence interval (CI) 1.49-1.63) in parents to 1.11 (95% CI 1.07-1.16) in cousins. The risk of death by suicide also increased alongside narrowing genetic distance, but was only significant in parents (OR 1.55; 95% CI 1.40-1.72) and full siblings (OR 1.80; 95% CI 1.43-2.26) of individuals with OCD. Familial coaggregation of OCD and suicide attempts was explained by additive genetic factors (60.7%) and non-shared environment (40.4%), with negligible contribution of shared environment. Similarly, familial coaggregation with death by suicide was attributed to additive genetics (65.8%) and nonshared environment (34.2%). Collectively, these observations indicate that OCD and suicidal behaviors coaggregate in families largely due to genetic factors. The contribution of unique environment is also considerable, providing opportunities to target high-risk groups for prevention and treatment.

Assessment of Cesarean Delivery and Neurodevelopmental and Psychiatric Disorders in the Children of a Population-Based Swedish Birth Cohort

IMPORTANCE

Recent studies suggest that cesarean delivery (CD) is associated with increased risk of neurodevelopmental disorders in children, although they were unable to control for indications for CD or familial confounding beyond full siblings.

OBJECTIVE

To examine the association between CD and neurodevelopmental and psychiatric disorders in children.

DESIGN, SETTING, AND PARTICIPANTS

This Swedish register-based cohort study included 1 179 341 term-birth singletons born between January 1, 1990, and December 31, 2003, and followed up through December 31, 2013. All individuals were linked to their full siblings, maternal and paternal half siblings, and maternal full cousins. Statistical analyses were performed from September 26, 2019, to January 16, 2021.

EXPOSURES

Birth by CD recorded at birth, stratified into planned and intrapartum CD.

MAIN OUTCOMES AND MEASURES

Registered diagnoses of neurodevelopmental disorders, including attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorders (ASD), intellectual disability, tic disorders, communication disorders, learning disorders, and any neurodevelopmental disorder; and psychiatric disorders, including anxiety disorders, obsessive-compulsive disorder, depressive disorders, eating disorders, bipolar disorders, psychotic disorders, and any psychiatric disorder.

RESULTS

Of 1 179 341 individuals, 1 048 838 (533 140 boys [50.8%]) were delivered vaginally, 59 514 (30 138 boys [50.6%]) were delived via planned CD, and 70 989 (39 191 boys [55.2%]) were delivered via intrapartum CD. Mean (SD) age at follow-up was 17.7 (4.1) years for vaginal delivery, 16.6 (4.2) years for planned CD, and 16.8 (4.1) years for intrapartum CD. Compared with vaginal delivery, and after controlling for measured covariates (parental and neonatal characteristics, maternal comorbidities, and pregnancy complications), CD was associated with higher risk in children of any neurodevelopmental disorder (planned CD, hazard ratio [HR], 1.17; 95% CI, 1.13-1.22; intrapartum CD, HR, 1.10; 95% CI, 1.05-1.14), ADHD (planned CD, HR, 1.17; 95% CI, 1.12-1.23; intrapartum CD, HR, 1.10; 95% CI, 1.05-1.15), and intellectual disability (planned CD, HR, 1.26; 95% CI, 1.14-1.39; intrapartum CD, HR, 1.17; 95% CI, 1.06-1.28). Only planned CD was associated with a higher risk of ASD (HR, 1.20; 95% CI, 1.10-1.31), communication disorders (HR, 1.14; 95% CI, 1.02-1.28), and learning disorders (HR, 1.15; 95% CI, 1.01-1.30). Cesarean delivery was not associated with the remaining disorders. The associations between CD and any neurodevelopmental disorder, ADHD, ASD, and intellectual disability attenuated in full cousins and paternal half siblings, and further attenuated (became nonsignificant) in maternal half siblings and full siblings (risk of any neurodevelopmental disorder in full siblings, planned CD, HR, 0.93; 95% CI, 0.81-1.06; intrapartum CD, HR, 1.07; 95% CI, 0.96-1.21).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that the association between CD and increased risk of neurodevelopmental disorders in the children was most likely explained by unmeasured familial confounding.

Comparing eating disorder characteristics and treatment in self-identified competitive athletes and non-athletes from the National Eating Disorders Association online screening tool

OBJECTIVE

We compared eating disorder (ED) characteristics and treatment seeking behaviors between self-identified competitive athletes and non-athletes in a large, community-based sample.

METHOD

During the 2018 National Eating Disorders Awareness Week, 23,920 respondents, 14.7% of whom identified as competitive athletes, completed the National Eating Disorders Association online screen. Data were collected on demographics, disordered eating behaviors, probable ED diagnosis/risk, treatment history, and intent to seek treatment.

RESULTS

The sample was predominantly White (81.8%), female (90.3%), and between 13 and 24 years (82.6%). Over 86% met criteria for an ED/subthreshold ED, and of those, only 2.5% were in treatment. Suicidal ideation was reported in over half of the sample. Athletes reported a significantly greater likelihood of engaging in and more frequent excessive exercise episodes than non-athletes. Athletes also reported a significantly lower likelihood of engaging in and less frequent binge-eating episodes compared with non-athletes. Athletes were more likely to screen positive for an ED/subthreshold ED than non-athletes, but percentages across all probable ED diagnoses were similar. No significant differences between athletes and non-athletes emerged on treatment history or intention to seek treatment post-screen (less than 30%).

DISCUSSION

Although the distribution of probable ED diagnoses was similar in athletes and non-athletes, symptom profiles related to disordered eating behavior engagement and frequency may differ. Athletes may be less likely to seek treatment due to stigma, accessibility, and sport-specific barriers. Future work should directly connect survey respondents to tailored treatment tools and increase motivation to seek treatment.

Latent Class Analysis of Self-directed Violence and Indirect Self-harm Behaviors: Gender Differences and Associations With Mental Health Symptoms

OBJECTIVE

This study aimed to (1) examine whether the latent class structure of individuals engaging in self-directed violence and indirect self-harm behaviors (eg, substance use, disordered eating) varied by gender in a sample of US veterans, and (2) test the associations of posttraumatic stress disorder (PTSD) and depressive symptoms with the resulting classes.

STUDY DESIGN

Cross-sectional data from 3581 veterans, ages 18-50 (51.9% identified as women) were analyzed. Veterans self-reported histories of self-directed violence, substance use, and disordered eating. Latent class analysis and latent class regression were used to explore class structure by gender and examine association of class membership with PTSD and depressive symptoms.

RESULTS

A 4-class model was supported in the sample. Class 1 (20.0%) was characterized by substance use and self-directed violent thoughts and behaviors. Class 2 (8.3%) was characterized by substance use, disordered eating, and self-directed violent thoughts and behaviors. Class 3 (12.6%) was distinguished by indirect self-harm behaviors (substance use and disordered eating). Class 4 (59.6%) reflected low likelihood of behavioral dysregulation. Classes were partially invariant across gender; endorsement of substance use behaviors was generally higher for men in each class. Comorbid clinically significant depressive and PTSD symptoms were associated with the class characterized by highest behavioral dysregulation.

CONCLUSIONS

Self-directed violent thoughts and behaviors present comorbidly with indirect self-harm in men and women veterans, although patterns of indirect self-harm behaviors differ slightly by gender. Such comorbidity may be associated with more severe presentations of psychiatric concerns.

Do borderline personality disorder and attention-deficit/hyperactivity disorder co-aggregate in families? A population-based study of 2 million Swedes

Large-scale family studies on the co-occurrence of attention-deficit/hyperactivity disorder (ADHD) and borderline personality disorder (BPD) are lacking. Thus, we aimed to estimate the co-occurrence and familial co-aggregation of clinically ascertained ADHD and BPD diagnoses using the entire Swedish population. In a register-based cohort design we included individuals born in Sweden 1979-2001, and identified their diagnoses during 1997-2013; in total, 2,113,902 individuals were included in the analyses. We obtained clinical diagnoses of ADHD and BPD from inpatient and outpatient care. Individuals with an ADHD diagnosis had an adjusted (for birth year, sex, and birth order) odds ratio (aOR) of 19.4 (95% confidence interval [95% CI] = 18.6-20.4) of also having a BPD diagnosis, compared to individuals not diagnosed with ADHD. Having a sibling with ADHD also increased the risk for BPD (monozygotic twins, aOR = 11.2, 95% CI = 3.0-42.2; full siblings, aOR = 2.8, 95% CI = 2.6-3.1; maternal half-siblings, aOR = 1.4, 95% CI = 1.2-1.7; paternal half-siblings, aOR = 1.5, 95% CI = 1.3-1.7). Cousins also had an increased risk. The strength of the association between ADHD and BPD was similar in females and males, and full siblings showed similar increased risks regardless of sex. Among both males and females, ADHD and BPD co-occur within individuals and co-aggregate in relatives; the pattern suggests shared genetic factors and no robust evidence for etiologic sex differences was found. Clinicians should be aware of increased risks for BPD in individuals with ADHD and their relatives, and vice versa.

Genetic and environmental contributions to diagnostic fluctuation in anorexia nervosa and bulimia nervosa

BACKGROUND

Anorexia nervosa and bulimia nervosa are two severe eating disorders associated with high premature mortality, suicidal risk and serious medical complications. Transition between anorexia nervosa and bulimia nervosa over the illness course and familial co-aggregation of the two eating disorders imply aetiological overlap. However, genetic and environmental liabilities to the overlap are poorly understood. Quantitative genetic research using clinical diagnosis is needed.

METHODS

We acquired a clinical diagnosis of anorexia nervosa (prevalence = 0.90%) and bulimia nervosa (prevalence = 0.48%) in a large population-based sample (N = 782 938) of randomly selected full-sisters and maternal half-sisters born in Sweden between 1970 and 2005. Structural equation modelling was applied to quantify heritability of clinically diagnosed anorexia nervosa and bulimia nervosa and the contributions of genetic and environmental effects on their overlap.

RESULTS

The heritability of clinically diagnosed anorexia nervosa and bulimia nervosa was estimated at 43% [95% confidence interval (CI) (36-50%)] and 41% (31-52%), respectively, in the study population, with the remaining variance explained by variance in unique environmental effects. We found statistically significant genetic [0.66, 95% CI (0.49-0.82)] and unique environmental correlations [0.55 (0.43-0.66)] between the two clinically diagnosed eating disorders; and their overlap was about equally explained by genetic and unique environmental effects [co-heritability 47% (35-58%)].

CONCLUSIONS

Our study supports shared mechanisms for anorexia nervosa and bulimia nervosa and extends the literature from self-reported behavioural measures to clinical diagnosis. The findings encourage future molecular genetic research on both eating disorders and emphasize clinical vigilance for symptom fluctuation between them.

The attributes of hospital-based coronary artery diseases registries with a focus on key registry processes: A systematic review

BACKGROUND

The management of data on coronary artery disease (CAD) plays a significant role in controlling the disease and reducing the mortality of patients. The diseases registries facilitate the management of data.

OBJECTIVE

This study aimed to identify the attributes of hospital-based CAD registries with a focus on key registry processes.

METHOD

In this systematic review, we searched for studies published between 2000 and 2019 in PubMed, Scopus, EMBASE and ISI Web of Knowledge. The search terms included coronary artery disease, registry and data management (MeSH terms) at November 2019. Data gathering was conducted using a data extraction form, and the content of selected studies was analysed with respect to key registry processes, including case finding, data gathering, data abstracting, data quality control, reporting and patient follow-up.

RESULTS

A total of 17,604 studies were identified in the search, 55 of which were relevant studies that addressed the 21 registries and were selected for the analysis. Results showed that the most common resources for case finding included admission and discharge documents, physician's reports and screening results. Patient follow-up was mainly performed through direct visits or via telephone calls. The key attributes used for checking the data quality included data accuracy, completeness and definition.

CONCLUSION

CAD registries aim to facilitate the assessment of health services provided to patients. Putting the key registry processes in place is crucial for developing and implementing the CAD registry. The data quality control, as a CAD registry process, requires developing standard tools and applying appropriate data quality attributes.

IMPLICATIONS

The findings of the current study could lay the foundation for successful design and development of CAD registries based on the key registry processes for effective data management.

Alcohol Use Disorder and Risk of Suicide in a Swedish Population-Based Cohort

OBJECTIVE

The authors examined the association between alcohol use disorder (AUD) and risk of suicide, before and after accounting for psychiatric comorbidity, and assessed the extent to which the observed association is due to a potentially causal mechanism or genetic and familial environmental confounding factors that increase risk for both.

METHODS

Longitudinal population-wide Swedish medical, criminal, and pharmacy registries were used to evaluate the risk of death by suicide as a function of AUD history. Analyses employed prospective cohort and co-relative designs, including data on 2,229,880 native Swedes born between 1950 and 1970 and observed from age 15 until 2012.

RESULTS

The lifetime rate of suicide during the observation period was 3.54% for women and 3.94% for men with AUD, compared with 0.29% and 0.76% of women and men, respectively, without AUD. In adjusted analyses, AUD remained robustly associated with suicide: hazard ratios across observation periods ranged from 2.61 to 128.0 among women and from 2.44 to 28.0 among men. Co-relative analyses indicated that familial confounding accounted for some, but not all, of the observed association. A substantial and potentially causal relationship remained after accounting for a history of other psychiatric diagnoses.

CONCLUSIONS

AUD is a potent risk factor for suicide, with a substantial association persisting after accounting for confounding factors. These findings underscore the impact of AUD on suicide risk, even in the context of other mental illness, and implicate the time frame shortly after a medical or criminal AUD registration as critical for efforts to reduce alcohol-related suicide.

Suicide attempts requiring hospitalization in patients with eating disorders: A retrospective cohort study

OBJECTIVE

Suicide attempts requiring hospitalization are known to be common in patients who are diagnosed with eating disorders. Attempting suicide is a major indicator for those at risk of completed suicide. Both the specific eating disorder diagnosis and the influence of psychiatric comorbidities on suicide attempts requiring hospitalization were investigated, with demographic and socioeconomic variables as confounders, over a 10-year observation period from January 2007 to March 2017.

METHODS

Anonymized health-record data from the South London and Maudsley NHS Foundation Trust (SLaM) were retrieved through the Clinical Record Interactive Search (CRIS) data resource; this is linked to national Hospital Episode Statistics (HES) data. These data include all diagnoses for inpatient admissions. Hazard ratios, with 95% confidence intervals (CIs), were calculated from cox regression analyses and the effects of a number of confounders were estimated by performing multivariable analyses.

RESULTS

In total, 4,895 patients were diagnosed with anorexia nervosa (AN), bulimia nervosa (BN), or eating disorder otherwise not specified (EDNOS). Of these, 331 (6.7%) had attempted suicide requiring hospitalization and 21 (0.04%) completed suicide. The eating disorder category associated with the highest risk of a suicide attempt was AN (HR: 1.43, 95%CI: 1.08-1.89, p = .01). The risk was significantly increased further if the patient had a comorbid diagnosis of personality disorder, depression, bipolar affective disorder, and substance misuse.

DISCUSSION

Suicide attempts requiring hospitalization have a high incidence rate among patients with eating disorders, and the risk is significantly increased in AN. Comorbid psychiatric illness and suicidal ideation should be carefully assessed in all eating disorder patients.

Familial Coaggregation of Asthma and Type 1 Diabetes in Children

IMPORTANCE

The association between atopic and autoimmune disease, particularly asthma and type 1 diabetes, has been debated. Further understanding of the underlying factors associated with the comorbidity in children is warranted.

OBJECTIVES

To assess the bidirectional association between asthma and type 1 diabetes and examine the possibility of a shared risk for the diseases by studying their pattern of familial coaggregation.

DESIGN, SETTING, AND PARTICIPANTS

A birth cohort study of children born from January 1, 2001, and followed up until December 31, 2015, was performed. Population data were obtained from multiple national Swedish registers. A total of 1 347 901 singleton children, live-born in Sweden between January 1, 2001, and December 31, 2013, were identified, and children with incomplete data were excluded. The remaining 1 284 748 children were linked to their biological full siblings, maternal and paternal half-siblings, cousins, and half-cousins. Data analysis was conducted from April 1, 2019, to January 17, 2020.

MAIN OUTCOMES AND MEASURES

Cases of asthma and type 1 diabetes were defined using a combination of diagnoses and medication prescriptions found in the registers.

RESULTS

In the cohort of 1 284 748 children, 660 738 children (51.4%) were boys; 121 809 children (9.5%) had asthma, 3812 children (0.3%) had type 1 diabetes, and 494 children had both asthma and type 1 diabetes, representing 0.4% of all asthma or 13% of all type 1 diabetes. Mean (SD) age at diagnosis was 3.0 (2.8) years for children with asthma, and 5.9 (3.3) years for those with type 1 diabetes. Asthma and type 1 diabetes were associated within individuals (odds ratio, 1.15; 95% CI, 1.05-1.27). Children with asthma had an increased risk of subsequent type 1 diabetes (hazard ratio, 1.16; 95% CI, 1.06-1.27); however, subsequent asthma risk did not differ substantially among children with type 1 diabetes (hazard ratio, 0.92; 95% CI, 0.75-1.12). Siblings of individuals with asthma were at an increased risk of type 1 diabetes (odds ratio, 1.27; 95% CI, 1.13-1.42) and vice versa. The results remained positive after controlling for the direct association of one disease with the other.

CONCLUSIONS AND RELEVANCE

This study appears to provide evidence for co-occurrence, importance of sequential appearance, and coaggregation of asthma and type 1 diabetes in children and their siblings. The findings may suggest shared familial factors contributing to the associations. Knowledge of the nature of the association could be of importance in future clinical practice.

Understanding suicide risk and eating disorders in college student populations: Results from a National Study

OBJECTIVE

To examine suicide risk by eating disorder severity and symptom presentation in a nationwide sample of college students.

METHOD

The Healthy Minds Study is the largest mental health survey of college populations in the United States. We analyzed the most recent available data (2015-2017) with 71,712 randomly selected students from 77 campuses. We estimated associations between two measures of suicidality (ideation and attempts) and three validated measures of eating disorder symptoms (the SCOFF, weight concerns scale, and the eating disorder examination questionnaire binge and purge items). Importantly, we also controlled for co-occurring symptoms of depression and anxiety, based on validated screening tools. The large, diverse sample provided a unique opportunity to assess whether certain individual characteristics were associated with increased risk.

RESULTS

Eating disorder symptoms, even at subthreshold levels, were highly predictive of suicidality. Relative to students with no apparent eating disorder symptoms, students with the highest symptom levels (a SCOFF score of 5) had 11 times higher odds of attempting suicide, while those with subthreshold symptoms had two times higher odds. We also observed a strong association between suicide attempts and eating disorder presentations that included purging. Students from marginalized backgrounds, particularly gender and sexual minorities, were at increased risk for suicide and eating disorders.

DISCUSSION

In the largest known study to date, findings suggest that eating disorders should be a priority within broader campus suicide prevention efforts, should be assessed along a continuum of severity and symptom presentation, and should focus on reaching vulnerable students.

Emergency Management in Eating Disorders

Aims and Scope::

Eating disorders commonly present during the adolescent and young adult years, and are complex in that they are a group of psychiatric diagnoses with medical complications.

Methods::

The diagnosis of an eating disorder can often go undetected while a patient is being evaluated for organic causes of weight loss. Anorexia nervosa, in particular, has the highest mortality rate of any psychiatric diagnosis. In the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5), there are several diagnoses that are classified as eating or feeding disorders.

Conclusion::

This article will discuss anorexia nervosa and bulimia nervosa, with a focus on medical and psychiatric emergencies that are important for primary care providers to keep in mind when caring for adolescents and young adults.

Siblings of Individuals With Eating Disorders: A Review of the Literature

Eating disorders (EDs) are serious psychopathologies characterized by a persistent disturbance in eating or eating-related behavior. Studies have shown EDs' detrimental consequences not only for patients, but also for their families. Nevertheless, a specific group that has so far been neglected, in both the research and clinical fields, are siblings of individuals with EDs. In an effort to identify this population's needs, and to facilitate effective prevention and treatment, this paper aims to review the existing literature on the subject, and examine siblings' personal experience, ways of coping, and levels of psychopathology. PubMed and PsycNet databases were searched with no publication date restrictions, yielding 26 relevant papers. Studies were categorized according to common themes they addressed, and subsequently summarized by highlighting common features, as well as information unique to each study. Several themes emerged, including emotional well-being, psychopathology, social consequences, family dynamics, and coping strategies. Results show that EDs experienced by one individual have significant effects on one's siblings, such as a decrease in quality of life, social isolation, and elevated familial strain. In several studies siblings were found to have elevated levels of psychopathology and EDs related symptoms. Nevertheless, findings' nature and magnitude were highly varied. The review indicates the need for further studies that will examine possible intra- and interpersonal moderating factors for EDs' impact on well-being among siblings, and take into consideration the substantial heterogeneity in studies conducted thus far. Additionally, this review highlights the need for novel and effective interventions, specifically targeting this at-risk group.

A longitudinal examination of the relationship between eating disorder symptoms and suicidal ideation

OBJECTIVE

Cross-sectional research demonstrates significant correlations between eating disorders (EDs) and suicidal thoughts and behaviors. Although suicide ideation (SI) is a risk factor for suicidal behavior, longitudinal research investigating SI among EDs is limited. Thus, the aim of this study was to offer insight into the dynamic relationship between EDs and SI by investigating if these variables predicted one another at weekly time points.

METHOD

Autoregressive cross-lagged modeling was used to test bidirectional relationships between ED symptoms and suicidal ideation among an ED patient sample (n = 92). Participants completed a measure of suicidal ideation and the Eating Disorder Examination-Questionnaire (EDE-Q) weekly for 5 weeks.

RESULTS

SI and ED symptoms were correlated with each other at each time point. Unexpectedly, the majority of cross-lagged pathways were nonsignificant. However, SI at Week 4 predicted ED symptoms at Week 5, while controlling for Week 4 ED symptoms. This pattern of results was found when the shape concerns, weight concerns, and eating concerns subscales of the EDE-Q were entered into the model. Moreover, Week 2 shape concerns predicted Week 3 SI and Week 3 eating concerns predicted Week 4 SI. No significant cross-lagged pathways were found with the dietary restraint subscale.

DISCUSSION

Nonsignificant cross-lagged pathways may indicate that third variables better explain the relations between certain ED symptoms and SI over time. However, there were instances where ED symptoms and SI predicted one another. Given this, targeting suicidal thoughts in therapy may help to reduce eating pathology and vice versa.

Genetic correlations of psychiatric traits with body composition and glycemic traits are sex- and age-dependent

Body composition is often altered in psychiatric disorders. Using genome-wide common genetic variation data, we calculate sex-specific genetic correlations amongst body fat %, fat mass, fat-free mass, physical activity, glycemic traits and 17 psychiatric traits (up to N = 217,568). Two patterns emerge: (1) anorexia nervosa, schizophrenia, obsessive-compulsive disorder, and education years are negatively genetically correlated with body fat % and fat-free mass, whereas (2) attention-deficit/hyperactivity disorder (ADHD), alcohol dependence, insomnia, and heavy smoking are positively correlated. Anorexia nervosa shows a stronger genetic correlation with body fat % in females, whereas education years is more strongly correlated with fat mass in males. Education years and ADHD show genetic overlap with childhood obesity. Mendelian randomization identifies schizophrenia, anorexia nervosa, and higher education as causal for decreased fat mass, with higher body fat % possibly being a causal risk factor for ADHD and heavy smoking. These results suggest new possibilities for targeted preventive strategies.

Associations Between Attention-Deficit/Hyperactivity Disorder and Various Eating Disorders: A Swedish Nationwide Population Study Using Multiple Genetically Informative Approaches

BACKGROUND

Although attention-deficit/hyperactivity disorder (ADHD) and eating disorders (EDs) frequently co-occur, little is known about the shared etiology. In this study, we comprehensively investigated the genetic association between ADHD and various EDs, including anorexia nervosa (AN) and other EDs such as bulimia nervosa.

METHODS

We applied different genetically informative designs to register-based information of a Swedish nationwide population (N = 3,550,118). We first examined the familial coaggregation of clinically diagnosed ADHD and EDs across multiple types of relatives. We then applied quantitative genetic modeling in full-sisters and maternal half-sisters to estimate the genetic correlations between ADHD and EDs. We further tested the associations between ADHD polygenic risk scores and ED symptoms, and between AN polygenic risk scores and ADHD symptoms, in a genotyped population-based sample (N = 13,472).

RESULTS

Increased risk of all types of EDs was found in individuals with ADHD (any ED: odds ratio [OR] = 3.97, 95% confidence interval [CI] = 3.81, 4.14; AN: OR = 2.68, 95% CI = 2.15, 2.86; other EDs: OR = 4.66, 95% CI = 4.47, 4.87; bulimia nervosa: OR = 5.01, 95% CI = 4.63, 5.41) and their relatives compared with individuals without ADHD and their relatives. The magnitude of the associations decreased as the degree of relatedness decreased, suggesting shared familial liability between ADHD and EDs. Quantitative genetic models revealed stronger genetic correlation of ADHD with other EDs (.37, 95% CI = .31, .42) than with AN (.14, 95% CI = .05, .22). ADHD polygenic risk scores correlated positively with ED symptom measures overall and with the subscales Drive for Thinness and Body Dissatisfaction despite small effect sizes.

CONCLUSIONS

We observed stronger genetic association with ADHD for non-AN EDs than for AN, highlighting specific genetic correlation beyond a general genetic factor across psychiatric disorders.

Reconceptualizing anorexia nervosa

Anorexia nervosa (AN) has one of the highest mortality rates of any psychiatric disorder. Treatments are often ineffective and relapse is common. Most research attempting to understand the underlying causes and maintenance factors of AN has focused on environmental contributions, yet there is much to be explored in terms of biological risk and maintenance factors. In this paper, we focus primarily on AN research related to genetics and the complex microbial community in the gut (intestinal microbiota), and how these impact our conceptualization of this disorder. Emerging research identifying significant negative genetic correlations between AN and obesity suggests that the conditions may represent 'metabolic bookends'. The identification of underlying biological mechanisms may provide both insight into extreme weight dysregulation on both ends of the spectrum and new possible points of entry for AN treatment. Additionally, the reported microbial imbalance (dysbiosis) in the gut microbiota in AN patients, potentially due to a nutrient- and energy-deprived gut environment, implies alterations in functional and metabolic capacity of the gut microbiome. The extent to which AN and obesity can also be considered to be 'microbiome bookends' requires further investigation. Finally, we discuss ongoing and future AN projects exploring the interplay between host genomics, the environment, and cumulative microbial genomes (microbiome) as well as interventions at the microbial and gut level.

Expressive suppression mediates the relation between disordered eating and suicidal ideation

OBJECTIVE

Although disordered eating is robustly associated with suicidal thoughts, it is not well understood why these conditions relate to each other. Emotion dysregulation is a shared risk factor for disordered eating and suicidal thoughts. Individuals with dysregulated emotions struggle to select appropriate strategies to modulate emotions and the strategies they use might explain some of the shared variances. Thus, we examined whether emotion regulation strategies mediated the relationship between disordered eating and suicidal ideation.

METHOD

Adult participants (N = 230) completed questionnaires on current disordered eating symptoms, emotion regulation strategies, and current suicidal ideation.

RESULTS

Disordered eating symptoms positively associated with suicidal ideation. In addition, expressive suppression mediated the relation between disordered eating symptoms and current suicidal ideation. No relation was found for cognitive reappraisal.

CONCLUSIONS

The use of expressive suppression as an emotion regulation strategy may be related to increased suicidal ideation in individuals who express concerns about eating.

Bidirectional relationship between eating disorders and autoimmune diseases

BACKGROUND

Immune system dysfunction may be associated with eating disorders (ED) and could have implications for detection, risk assessment, and treatment of both autoimmune diseases and EDs. However, questions regarding the nature of the relationship between these two disease entities remain. We evaluated the strength of associations for the bidirectional relationships between EDs and autoimmune diseases.

METHODS

In this nationwide population-based study, Swedish registers were linked to establish a cohort of more than 2.5 million individuals born in Sweden between January 1, 1979 and December 31, 2005 and followed up until December 2013. Cox proportional hazard regression models were used to investigate: (a) subsequent risk of EDs in individuals with autoimmune diseases; and (b) subsequent risk of autoimmune diseases in individuals with EDs.

RESULTS

We observed a strong, bidirectional relationship between the two illness classes indicating that diagnosis in one illness class increased the risk of the other. In women, the diagnoses of autoimmune disease increased subsequent hazards of anorexia nervosa (AN), bulimia nervosa (BN), and other eating disorders (OED). Similarly, AN, BN, and OED increased subsequent hazards of autoimmune diseases.Gastrointestinal-related autoimmune diseases such as, celiac disease and Crohn's disease showed a bidirectional relationship with AN and OED. Psoriasis showed a bidirectional relationship with OED. The previous occurence of type 1 diabetes increased the risk for AN, BN, and OED. In men, we did not observe a bidirectional pattern, but prior autoimmune arthritis increased the risk for OED.

CONCLUSIONS

The interactions between EDs and autoimmune diseases support the previously reported associations. The bidirectional risk pattern observed in women suggests either a shared mechanism or a third mediating variable contributing to the association of these illnesses.