Clinical characteristics in patients with anorexia nervosa and obsessive-compulsive disorder

Obsessive-compulsive symptoms in young women affected with anorexia nervosa, and their relationship with personality, psychopathology, and attachment style

PURPOSE

Obsessive-compulsive symptoms (OC) are associated with greater morbidity and worse prognosis in anorexia nervosa (AN). We assessed the presence of non-eating OC in participants with AN and related them with their psychopathology, personality, and attachment style features.

METHODS

Young women with AN (N = 41, 30 restrictor and 11 binge-purging type) were assessed on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). These participants with AN and 82 healthy controls (HC) completed the Temperament and Character Inventory (TCI), Eating Disorder Inventory-2 (EDI-2), Symptom Checklist-90 (SCL-90), Toronto Alexithymia Scale (TAS-20), and Attachment Style Questionnaire (ASQ). The association between Y-BOCS scores and indexes of psychopathology, personality, and attachment were examined.

RESULTS

AN had significantly higher scores than HC on the EDI-2, SCL-90, TAS-20, ASQ-Need for Approval, and TCI-Harm Avoidance and Self-directedness. The Y-BOCS scores were significantly correlated with ASQ-Need for Approval, TAS-20-Difficulty in Describing Feelings, SCL-90-Phobic Anxiety, and Anxiety, EDI-2-Drive to Thinness, and Asceticism. Need for Approval displayed the strongest correlation with OC symptoms. Difficulty in describing feelings displayed the strongest correlation with compulsive OC symptoms.

CONCLUSIONS

OC traits in AN were primarily associated with measures of insecure attachment rather than to their eating disorder or general psychopathology. Therapeutic approaches to correcting insecure attachment may be considered as a possible approach to treating AN patients with OC. The study supports a new psychopathological perspective for understanding the meaning of OC symptoms in AN.

LEVEL OF EVIDENCE

III: Evidence obtained from cohort or case-control analytic studies.

The Association of Obsessive-Compulsive Disorder, Anxiety Disorders, and Posttraumatic Stress Disorder with Impairment Related to Eating Pathology

Prior work has shown a number of similarities between obsessive-compulsive disorder (OCD) and eating disorders such as perfectionism and depressive symptoms. However, distress and impairment due to eating pathology are also highly comorbid with other disorders, which brings into question whether the relationship with eating pathology is unique to OCD. The aims of the current study were 1) to test perfectionism and depression as mediators of the relationship between OCD and eating pathology, and 2) to determine whether OCD is related to greater distress/impairment regarding eating habits, exercising, or feelings about eating, shape, or weight above and beyond other disorders. Symptoms were assessed in 329 treatment-seeking patients in a secondary analysis of a clinical battery. The results showed that depressive symptoms and perfectionism were found to mediate the relationship between OCD and eating pathology. Additionally, a regression analysis showed that OCD, social anxiety disorder, and panic disorder symptoms were associated with eating pathology to a greater extent than other disorders. These results suggest that distress and impairment related to eating habits, exercising, or feelings about eating, shape, or weight are not unique to OCD and that depression and perfectionism may, in part, explain the association between OCD and eating pathology.

Comorbid obsessive-compulsive disorder in individuals with eating disorders: An epidemiological meta-analysis

The present study aimed to provide a precise, meta-analytic estimate of the prevalence of obsessive-compulsive disorder (OCD) amongst those with a current primary eating disorder (ED) diagnosis, and to isolate its predictors. An online search of PubMed and PsycINFO was conducted with a Boolean search phrase incorporating keywords related to OCD, EDs, comorbidity, prevalence, and epidemiology, complemented by references coded from related review articles and contact with experts in the field. Articles were included if they (a) reported an observational study examining current ED diagnoses, (b) used a semi-structured or structured diagnostic interview for OCD and ED diagnosis, (c) applied DSM or ICD criteria, (d) included adolescent or adult samples (age > 12), (e) included patient or community samples, and (f) reported lifetime or current OCD comorbidity. From the 846 articles identified, 35 lifetime and 42 current estimates were calculated. OCD prevalence was extracted from each study for each ED diagnostic category, along with eleven additional potential moderators. Analyses revealed an aggregate lifetime OCD prevalence of 13.9% CI_95% [10.4 to 18.1] and current OCD prevalence of 8.7% CI_95% [5.8 to 11.8] across EDs. Moderator analyses revealed the prevalence of and risk for OCD in EDs to be greatest in anorexia nervosa binge-eating purging type (ANBP). Further, OCD is most prevalent amongst patient samples than samples recruited from the community.

Rates of comorbid obsessive-compulsive disorder in eating disorders: A meta-analysis of the literature

BACKGROUND

The high comorbidity between Eating Disorders (EDs) and Obsessive-Compulsive disorder (OCD) is well known, as well as its implications in terms of worse outcome and need to adapt treatment. Estimates of OCD comorbidities in EDs are variable in different studies and poorly informative for clinical purposes. In this study, we sought to derive more consistent estimates, taking into account potential methodological and sampling confounding factors.

METHODS

We searched published studies reporting lifetime and current rates of comorbid OCD in ED samples based on recent diagnostic criteria. Comorbidity rates were meta-analyzed using a binary random effects model. Heterogeneity among the studies and publication bias were systematically checked. Potential confounding factors were tested by meta-regression analysis and adjusted by sensitivity analysis.

RESULTS

Globally, respectively 18% and 15% of all patients with an ED had a lifetime and current comorbidity with OCD. Rates were slightly higher in anorexia (19% and 14%) than in bulimia nervosa (13% and 9%), although only the current comorbid OCD was significantly higher in anorexia than in bulimia. Prospective follow-up studies provided considerably higher lifetime estimates (EDs 38%, anorexia 44%, bulimia 19%).

LIMITATIONS

Temporal/causal relationship between ED and OCD could not be defined.

CONCLUSIONS

OCD comorbidity in EDs is a relevant phenomenon, affecting almost one fifth of the patients in cross-sectional observations and up to nearly 40% in prospective follow-up studies. These data indicate the need for focused attention to non-food or body-shape related OCD symptoms, for better diagnostic and prognostic accuracy, and targeted treatment.

Association of Orthorexic Tendencies with Obsessive-Compulsive Symptoms, Eating Attitudes and Exercise

PURPOSE

The term orthorexia nervosa is used to describe the pathological fixation associated with consuming healthy food. It is assumed that orthorexia nervosa shares some phenomenological features with anorexia nervosa, obsessive-compulsive disorder (OCD), and other mental disorders. Individuals with orthorexic tendencies may have high physical activity as well as a healthy diet. This study aimed to investigate the relationship of orthorexia nervosa with obsessive-compulsive symptoms, eating attitudes, and several sociodemographic features.

PATIENTS AND METHODS

We included 63 patients diagnosed with OCD, 63 healthy volunteers who perform physical exercises at least three days a week, at least 30 minutes a day, and 63 healthy volunteers who do not perform physical exercises regularly. Sociodemographic data form, Yale-Brown Obsessive Compulsive Scale, ORTO-11 Scale, Eating Attitude Test, Hamilton Anxiety Scale, and Structured Clinical Interview for DSM-5 Disorders (SCID-5 CV) were administered to all participants. OCD data form was also applied to patients with OCD diagnosis.

RESULTS

We found a statistically significant relationship between current order-symmetry obsessions and orthorexic tendencies in patients with OCD (p<0.05). There was no relationship between the severity of the disorder and orthorexia nervosa in patients with OCD (p>0.05). Orthorexic tendencies were found to increase as impaired eating attitudes increased in participants who regularly performed physical exercises and patients with OCD (p<0.05). The orthorexic tendencies of participants who regularly performed physical exercises were higher than those diagnosed with OCD and healthy individuals who did not perform physical exercises.

CONCLUSION

The absence of a significant relationship between disorder severity and orthorexia nervosa in patients diagnosed with OCD and the increase in orthorexic tendencies as the deterioration in eating attitudes increases in both patients with OCD and the participants who regularly perform physical exercises suggest that orthorexia nervosa may be closer to the eating disorders group than obsessive-compulsive spectrum. Studies with large samples and different diagnoses are needed to determine the place of orthorexia nervosa in diagnosis and classification systems.

Successful use of electroconvulsive therapy in a patient with anorexia nervosa and severe acute-onset obsessive-compulsive disorder

Anorexia nervosa (AN) is a complex condition that is often accompanied by several serious comorbidities that may require a variety of treatment modalities throughout the course of the illness. Obsessive-compulsive disorder (OCD), which is common in patients with AN, may occasionally cause serious interruptions to the daily functioning of the patient. We report on a 24-year-old male patient with chronic AN. During the beginning of his illness, he had a major depressive episode that was followed by AN onset. Throughout his illness, he also experienced chronic moderate depressive symptoms and later developed severe OCD. He experienced complete remission from the OCD and an improved mood after undergoing a course of bilateral electroconvulsive therapy (ECT). His OCD symptoms did not recur during the first year of follow-up. ECT may prove to be a fast and effective treatment strategy for severe and disabling acute-onset OCD that occurs during the course of comorbid AN. The case described herein shows how a comorbid psychiatric disorder in a patient suffering from chronic AN may disrupt the daily functioning of the patient if it is not urgently treated.

Comparative Prevalence of Eating Disorders in Obsessive-Compulsive Disorder and Other Anxiety Disorders

Objective. The purpose of this study was to compare the prevalence of comorbid eating disorders in Obsessive-Compulsive Disorder (OCD) and other common anxiety disorders. Method. 179 patients from the same geographical area with a diagnosis of OCD or an anxiety disorder were divided into two groups based on their primary diagnosis. The prevalence of a comorbid eating disorder was calculated in both groups. Results. There was no statistically significant difference in the prevalence of comorbid eating disorders between the OCD and other anxiety disorders group. Conclusions. These results suggest that the prevalence of comorbid eating disorders does not differ in anxiety disorders when compared with OCD. However, in both groups, it remains statistically higher than that of the general population.

Hypothalamic Agrp neurons drive stereotypic behaviors beyond feeding

The nervous system evolved to coordinate flexible goal-directed behaviors by integrating interoceptive and sensory information. Hypothalamic Agrp neurons are known to be crucial for feeding behavior. Here, however, we show that these neurons also orchestrate other complex behaviors in adult mice. Activation of Agrp neurons in the absence of food triggers foraging and repetitive behaviors, which are reverted by food consumption. These stereotypic behaviors that are triggered by Agrp neurons are coupled with decreased anxiety. NPY5 receptor signaling is necessary to mediate the repetitive behaviors after Agrp neuron activation while having minor effects on feeding. Thus, we have unmasked a functional role for Agrp neurons in controlling repetitive behaviors mediated, at least in part, by neuropeptidergic signaling. The findings reveal a new set of behaviors coupled to the energy homeostasis circuit and suggest potential therapeutic avenues for diseases with stereotypic behaviors.

Provocation of symmetry/ordering symptoms in Anorexia nervosa: a functional neuroimaging study

Anorexia nervosa (AN), obsessive–compulsive disorder (OCD), and obsessive–compulsive personality disorder (OCPD) are often co-morbid; however, the aetiology of such co-morbidity has not been well investigated. This study examined brain activation in women with AN and in healthy control (HC) women during the provocation of symmetry/ordering-related anxiety. During provocation, patients with AN showed more anxiety compared to HCs, which was correlated with the severity of symmetry/ordering symptoms. Activation in the right parietal lobe and right prefrontal cortex (rPFC) in response to provocation was reduced in the AN group compared with the HC group. The reduced right parietal activation observed in the AN group is consistent with parietal lobe involvement in visuospatial cognition and with studies of OCD reporting an association between structural abnormalities in this region and the severity of ‘ordering’ symptoms. Reduced rPFC activation in response to symmetry/ordering provocation has similarities with some, but not all, data collected from patients with AN who were exposed to images of food and bodies. Furthermore, the combination of data from the AN and HC groups showed that rPFC activation during symptom provocation was inversely correlated with the severity of symmetry/ordering symptoms. These data suggest that individuals with AN have a diminished ability to cognitively deal with illness-associated symptoms of provocation. Furthermore, our data also suggest that symptom provocation can progressively overload attempts by the rPFC to exert cognitive control. These findings are discussed in the context of the current neurobiological models of AN.

[Eating disorders (ED) and obsessive-compulsive disorders (OCD): common factors]

Several similarities exist in the phenomenology of obsessive-compulsive disorder (OCD) and eating disorders (ED : anorexia nervosa and bulimia). Both disorders include obsessive thoughts and compulsive or ritualized behaviours. Furthermore, these two disorders frequently present with similar comorbid disorders. In this article, the authors examine similarities between ED and OCD, and whether eating disorders can be conceptualized as a variant of obsessive-compulsive disorders. This raises the possibility that treatments proven effective for OCD could be successfully adapted for ED. The authors consequently further examine both treatments utilized for both disorders.

Typology of obsessive-compulsive symptoms in children and adolescents with anorexia nervosa

BACKGROUND

Previous studies have shown that symptoms of obsessive compulsive disorder are common in both adults and children and adolescents with anorexia nervosa. Until now, no study has explored the specific obsessive compulsive symptoms shown in children and adolescents with AN.

METHOD

In this study we report types of symptoms displayed by young people with AN and explore similarities and differences with adults with AN and with people with OCD.

RESULTS

Common obsessions concerned contamination, aggressive and somatic concerns, and common compulsions were related to ordering/arranging, and checking.

CONCLUSION

It is important for clinicians to be aware of the obsessions and compulsions they are most likely to encounter when working with these patients. If missed or ignored, such symptoms may interact with eating disorder symptoms and impede treatment.

Cognitive-behavioral flexibility in anorexia nervosa

Anorexia nervosa (AN) patients are characterized by perfectionism and obsessional personality traits. This anorectic personality type is associated with an exaggerated cognitive control and impaired cognitive-behavioral flexibility. Neuropsychological studies addressing flexibility have supported an impaired cognitive set-shifting (i.e., concrete and rigid behaviors to changing rules) as well as an impaired behavioral response shifting (i.e., stereotyped or perseverative behaviors) in AN patients independent of nutritional status and body weight. Furthermore, impaired set-shifting was found in healthy sisters of AN patients suggesting that cognitive inflexibility is a trait marker in AN patients. Brain imaging studies have provided new insights in striatocortical circuit dysfunctions that may underlie both the clinical symptoms of obsessive-compulsive personality traits and the neuropsychological observations of impaired cognitive-behavioral flexibility. The conceptualization of AN as a neurodevelopmental striatocortical disorder may help to develop new promising treatment approaches for this severe disorder.

The roles of persistence and perseveration in psychopathology

Two constructs were hypothesized to be of importance in psychological disorders: persistence (the ability to keep going to reach a goal, even when the task is difficult or drawn out) and perseveration (the tendency to continue a behavior, even when it ceases to be effective or rewarding). These are contrasted with perfectionism (having high standards for oneself or others). A measure was developed to address these constructs (the Persistence, Perseveration and Perfectionism Questionnaire; PPPQ). The PPPQ was administered to 325 nonclinical participants, alongside a measure of psychological disturbance. Factor analysis resulted in a 22-item version of the measure, consisting of subscales with good psychometric properties corresponding to the 3 theoretical constructs. Persistence was associated with lower levels of psychopathology, whereas perseveration was associated with higher levels of psychopathology. Perfectionism was weakly associated with psychopathology. Further work is needed to develop these constructs with clinical groups, but the findings support the hypothesis that persistence is an adaptive construct whereas perseveration is maladaptive.

Eating disorders and obsessive-compulsive disorder: A dimensional approach to purported relations

The purpose of this research was to investigate the specificity of purported relations between symptoms of eating disorders (ED) and obsessive-compulsive disorder (OCD). Whereas most research has focused on diagnostic comorbidity or between-groups analyses, this study took a dimensional approach to investigate specific relations among symptoms of anorexia, bulimia, and OCD, as well as panic, depression, and general distress in a student sample (N=465). Results were that all symptoms showed significant zero-order correlations, including all ED-OCD pairings. After removing general distress variance, however, none of three OCD scales significantly predicted anorexia; only compulsive washing among OCD scales significantly predicted bulimia. Hierarchical multiple regression demonstrated that panic and depression out-performed OCD in predicting bulimia symptoms. Overall, symptoms of ED and OCD did not show unique relations at the level of core dimensions of each construct. A possible link between bulimia and compulsive washing is worth further study.

SERT Ileu425Val in autism, Asperger syndrome and obsessive-compulsive disorder

BACKGROUND

SERT I425V, an uncommon missense single nucleotide polymorphism producing a gain-of-function of the serotonin transporter (SERT), was originally found to segregate with a primarily obsessive-compulsive disorder (OCD) but complexly comorbid phenotype in two unrelated families.

OBJECTIVE

As two individuals with SERT I425V and OCD also had Asperger syndrome (AS), an autism spectrum disorder, and as other rare SERT variants have recently shown significant associations with autism, we set out to extend our original OCD study by genotyping additional autism/AS and OCD samples.

METHODS

Case-control association study of SERT I425V in 210 AS/autism probands and 215 controls, plus 335 OCD probands and their family members.

RESULTS

SERT I425V was not found in any of the individuals with AS/autism, OCD alone or OCD comorbid with AS and other disorders, or in controls. This results in new estimates of SERT I425V having a 1.5% prevalence in 530 individuals with OCD from five unrelated families genotyped by us and by one other group and a 0.23% frequency in four control populations totaling 1300 individuals, yielding a continuing significant OCD-control difference (Fisher's exact test corrected for family coefficient of identity P=0.004, odds ratio=6.54).

CONCLUSION

As several other uncommon, less well quantitated genetic variations occur with an OCD phenotype, including chromosomal anomalies and some other rare gene variants (SGCE, GCH1 and SLITRK1), a tentative conclusion is that OCD resembles other complex disorders in being etiologically heterogeneous and in having both highly penetrant familial subtypes associated with rare alleles or chromosomal anomalies, as well as having a more common, polygenetic form that may involve polymorphisms in such genes as BDNF, COMT, GRIN2beta, TPH2, HTR2A and SLC1A1.

Obsessive-compulsive spectrum disorders: cross-national and ethnic issues

Epidemiological and clinical data from a variety of cultural and geographic settings on obsessive-compulsive disorder (OCD), and many of the obsessive-compulsive spectrum disorders, suggest that this is a group of disorders with a good degree of transcultural homogeneity. However, the content and themes that predominate in patients with these disorders, and the course of illness, can be shaped by cultural, ethnic, and religious experiences. Across cultures, OCD is commonly comorbid with mood, anxiety, and impulse-control disorders. However, little is known about the mechanisms by which culture and ethnicity may affect the expression of OCD and related disorders. Cross-national comparative studies exploring culturally influenced differences in clinical course, treatment outcome, including ethnogenetic differences in drug response, and prognosis are needed.

Decision-making functioning as a predictor of treatment outcome in anorexia nervosa

The pathological eating behaviour of patients with anorexia nervosa reflects a deficit in planning real-life strategies that can be observed in an experimental setting through the Gambling Task, a tool designed to detect and measure decision-making abilities. We examined the role of Gambling Task performance as a predictor of treatment outcome in anorectic patients, and we evaluated changes in decision-making after clinical improvement. Performance on the Gambling Task was evaluated, and a clinical-nutritional assessment of 38 anorectic patients was carried out before and after a cognitive-behavioural and drug treatment program. Task performance of anorectic patients was compared with that of 30 healthy control participants. Patients who had a better decision-making profile at baseline showed significantly greater improvement in nutritional status. The decision-making deficiency of some anorectic patients is probably linked to those individual features that contribute to the phenomenological expression of the disorder and to its different treatment outcomes.

Obsessive compulsive personality disorder and obsessive compulsive disorder: clinical characteristics, diagnostic difficulties, and treatment

BACKGROUND

The overlap between obsessive compulsive personality disorder (OCPD) and obsessive compulsive disorder (OCD) has received increasing recognition and continues to be a source of much debate. With the advent of new research methodologies, researchers have attempted to distinguish whether OCPD and OCD are two distinct phenomena that can co-occur or whether they are similar, overlapping constructs.

METHODS

MEDLINE was used to systematically review the OCPD and OCD literature published between 1991 and 2004.

RESULTS

Using the more stringent DSM-IV criteria, results from OCD clinical samples suggest that the majority of individuals with OCD (75%) do not have OCPD. Similarly, results from personality disorder samples suggest that the majority of individuals with OCPD (80%) do not have OCD.

CONCLUSIONS

While there is evidence that OCD and OCPD are linked, the literature does not support either one as a necessary or sufficient component of the other.

Psychopharmakotherapie mit Clomipramin und Paroxetin bei jugendlichen Patientinnen mit «Anorexia nervosa» und «Depressiver Episode» - eine Pilotstudie zu Verträglichkeit, Absetzquote und therapeutischen Verlaufskriterien

Zusammenfassung: Fragestellung: Die Frage der Indikation und Wirkung antidepressiver Medikation bei Anorexia nervosa mit Beginn im Kindes- und Jugendalter im Verlauf stationärer Behandlung wurde bislang nur wenig untersucht. Auch mangelt es an vergleichenden Studien zu Verträglichkeit und Wirkung unterschiedlicher Thymoleptika an anorektischen Patienten dieses Altersspektrums. Gegenstand der vorliegenden Studie war ein Vergleich der Behandlungsverläufe unter Paroxetin, einem SSRI, und Clomipramin, einem trizyklischen Antidepressivum mit serotonerger Wirkkomponente. Neben Qualität und Auftretenshäufigkeit unerwünschter Wirkungen sowie Häufigkeit und Ursachen des Absetzens der Medikation galt das Interesse verschiedenen therapeutischen Verlaufskriterien. Methodik: In die retrospektive Untersuchung wurden 83 Patientinnen einbezogen, die im Zeitraum von 1988 bis 1998 erstmalig stationär in der Klinik und Poliklinik für Kinder- und Jugendpsychiatrie und Psychotherapie der Universität Würzburg behandelt wurden. Alle Patientinnen erfüllten die Kriterien einer «Anorexia nervosa» sowie «Depressiven Episode» nach ICD-10 und erhielten eine antidepressive Medikation mit Paroxetin- oder Clomipramin. Grundlage der Datenerhebung waren Basisdokumentation, multiaxiale Klassifikation sowie Verlaufs- und Abschlussberichte. Als Kriterien des Therapieerfolgs wurden die Behandlungsdauer (Tage) und der Gewichtszuwachs (kg/m2) bestimmt. Ergebnisse: Clomipramin wurde im Behandlungsverlauf signifikant häufiger als Paroxetin aufgrund unerwünschter Wirkungen sowie einer unzureichenden Beeinflussung der depressiven Zielsymptomatik abgesetzt (33,3 vs. 15,4%). Unter Paroxetin wurde ein vergleichbarer Gewichtszuwachs (2,8 vs. 2,6 kg/m2) in signifikant kürzerer Behandlungsdauer (71,9 vs. 96,5 Tage) erreicht. Schlussfolgerung: Kürzere Behandlungsdauer, raschere Gewichtszunahme, geringere Absetzquote und nicht zuletzt wirtschaftliche Überlegungen sprechen für eine im Vergleich zu Clomipramin positive Indikation von Paroxetin bei jugendlichen Patientinnen mit «Anorexia nervosa» und «Depressiver Episode». Eine prospektive Wirksamkeitsstudie ist zu fordern, um die dargelegten Ergebnisse zu prüfen.

Symmetry, ordering and arranging compulsive behaviour

Compulsive ordering and arranging, and a preoccupation with symmetry are features of obsessive-compulsive disorder (OCD) that have not been examined experimentally. Three connected studies were conducted to examine this phenomenon: a self-report measure of this behaviour was developed and validated, participants were asked to engage in tasks designed to assess preferences for order, and to assess the interference of disorderly surroundings in the completion of a stressful activity. The self-report measure has sound psychometric properties and validity. Participants with a strong preference for order were made more anxious by having to complete a difficult task in a disorganized environment. Participants without this preference did not show this effect. The results are discussed in terms of the phenomenology of compulsive ordering and arranging, and its relationships with both OCD and normal human behaviour. It is suggested that compulsive ordering and a drive for symmetry are extreme manifestations of the common preference for order and symmetry.

Neuropsychological investigation of decision-making in anorexia nervosa

Anorexia nervosa (AN) could be considered a form of obsessive-compulsive disorder in which an impairment of the cognitive domain related to decision-making was found. We explored this function in AN patients, as well as possible differences between restricting type and binge/purge type, with the aim of examining the hypothesis that AN is part of the obsessive-compulsive spectrum. Decision-making was assessed in 59 inpatients with AN and 82 control subjects using the Gambling task, which simulates real-life decision-making by assessing the ability to balance immediate rewards against long-term negative consequences. We confirmed the supposed deficit of decision-making in AN. However, restricting and binge eating/purge subtypes showed different patterns of decision-making impairment. Poor performance on the Gambling task is not a mere consequence of starvation and does not appear to be related to illness severity. The decision-making deficiency that some AN patients show is linked to those individual features that contribute to the phenomenological expression of the disorder.

Is there a common mechanism of serotonin dysregulation in anorexia nervosa and obsessive compulsive disorder?

Numerous studies have documented increased rates of comorbidity in patients with anorexia nervosa (AN) or obsessive compulsive disorder (OCD). The interaction of many possible factors influences this comorbidity, but one possible explanation involves the neurotransmitter serotonin, which is widely distributed in the brain and has been implicated in a number of psychological behaviours. Although low serotonin levels have been found in patients with impulsive and aggressive behaviour, high levels have been correlated with obsessive and compulsive behaviour. In an attempt to further our understanding of this relationship, a large number of studies have measured serotonin levels throughout different stages of illness in both AN and OCD; furthermore, serotonin challenge studies and drug treatment trials have provided further support for this theory. This paper discusses the evidence supporting the view that the obsessive behaviour characteristic of AN and OCD may be partially due to a dysregulation in the serotonergic system.

Anorexia nervosa: obsessive-compulsive disorder, obsessive-compulsive personality disorder, or neither?

Anorexia nervosa (AN) is a severe and often chronic disorder with uncertain aetiology and poor prognosis. New approaches to the understanding of the disorder are needed in order to aid the development of more effective treatments. Several authors have suggested that AN has a considerable overlap with obsessive-compulsive disorder (OCD) and that this may reflect common neurobiological, genetic, or psychological elements. However, more recent studies have suggested that AN may have a closer relationship with obsessive-compulsive personality traits such as those found in obsessive-compulsive personality disorder (OCPD). In this paper, evidence for links between the three conditions is reviewed, suggestions for further research are outlined and possible implications for the treatment of AN are presented.

Anorexia nervosa: manifestations and management for the gastroenterologist

Anorexia nervosa is a complex psychiatric disorder with significant morbidity and mortality. It is important for gastroenterologists to be aware of the physiological effects and potential complications of anorexia nervosa, as they are frequently involved in treating patients with this disorder. We review the classic, GI, and neuroendocrinological features of anorexia nervosa. We also discuss gender differences and treatment options in anorexia nervosa. Further studies of GI physiology and pharmacology are needed to determine whether any disturbances may be amenable to therapeutic intervention. Future treatments directed at improving GI sensorimotor function and neurohormonal abnormalities in patients with anorexia nervosa may impact their nutritional rehabilitation and may have important health economic implications as patients avoid hospitalization and are restored to full activities in society. The current team approach, which incorporates psychiatrists, psychologists, nutritionists, pediatricians, internists, and gastroenterologists in the treatment of patients with anorexia nervosa, will continue to be essential.

A comparative study of clinical features between pure checkers and pure washers categorized using a lifetime symptom rating method

The current study assessed lifetime obsessive-compulsive disorder (OCD) symptoms in 156 Japanese patients with OCD in order to investigate clinical differences between pure lifetime checkers and pure lifetime washers. Fifty subjects (32%), who had no lifetime history of washing or checking compulsions, or who had a principal symptom other than washing or checking compulsions, were initially excluded. The remaining 106 subjects were divided into three groups: 43 pure lifetime washers (W), 33 pure lifetime checkers (C) and 30 subjects who had experienced both checking and washing compulsions over their lifetime (WC). No differences in clinical characteristics were observed between the W and C groups, suggesting that the lifetime washer-checker distinction may not be useful in subtyping OCD. However, subjects in the WC group differed from other subjects in a number of respects including poorer level of insight, more severe psychopathology and global dysfunction. Thus, they can be generally distinguished by more pervasive and severe psychopathological features, and may constitute a valid subgroup of OCD. Further work from a multidimensional perspective is required to verify the clinical significance of a typology based on lifetime symptoms.

Is DSM widely accepted by Japanese clinicians?

The Diagnostic and Statistical Manual of Mental Disorders, 3rd edition (DSM-III), a new standardized diagnostic system with multiaxial diagnosis, operational criteria and renewed definitions of mental disorders, was introduced in 1980 and prompted movements to reform conventions in Japanese psychiatry. This review overviews the initial response of Japanese clinicians to accept DSM-III, and its effects on the development of systematic research of psychiatric diagnosis. These new research activities include those on reliability of psychiatric diagnosis, application of various evaluation tools, discussion on the concept of mental disorders, relation of personality disorders with depressive disorders, and Taijin-kyofusho, or culturally distinctive phobia in Japan. A reference database search to survey the latest trend on psychiatric research indicated that the number of papers published by Japanese workers increased sharply after 1987, and DSM apparently greatly influenced their internationalization. Twenty years after the publication of DSM-III, a questionnaire on the use of DSM-IV was set out in 2000 to survey how widely DSM is utilized in clinical practice in Japan. Two hundred and twelve psychiatrists answered the questionnaire, and the results show that DSM has been accepted positively by the younger generation, while the older generation (over 40s) has still less interest in DSM, and DSM is used mainly for research purposes rather than in daily practice.

Perceptual illusions in eating disorders: rigid and fluctuating styles

This study investigated perceptual styles in anorexia nervosa (AN) and bulimia nervosa (BN) using a perceptual set task. We hypothesised that, consistent with personality style research. AN patients might be more rigid in style than those with BN or no eating disorder. We found that once an illusion had been established, participants with AN and BN showed more illusions than non-ED women. However, while AN patients responded rigidly, giving the same response repeatedly, BN patients were more likely to change their responses. The study suggests interesting differences to be followed up in future research. Differences in rigid and fluctuating perceptual styles may have implications for understanding the phenomenology of eating disorders, and have implications for treatment.

[Eating disorders among secondary students in a health area]

OBJECTIVES

To study the prevalence of eating disorders among adolescent in a health area. Design. Cross-sectional descriptive study.Setting. The primary care centres of secondary education.

PARTICIPANTS

Students with age between 13-16 years.

MEASUREMENTS

The validation of the Spanish translation of the Eating Attitudes Test-40 was administered to students, previous authorization of their parents. In the positive cases, we reported with a letter to their parents. The date were incorporate to a data base and in order to their treatment tools of analytic and descriptive statistic they were used.

RESULTS

There were 503 valid questionnaires (95% students of the health area). The absolute mean score was 13.42 points (CI, 12.57-14.28), in women 14.71 points and in man 11.82 points. According to age groups, the mean score for 13, 14.15 and 16 years was 14.05, 13.85, 13.08 and 12.60 points respectively. 16.97% presented >= 20 points (sensitivity, 91%; specificity, 69.2%) and 16.97% of the sample >= 30 points (sensitivity, 67,9%; specificity, 85.9%). There were more positive cases in women than men (2 = 22.4; p < 0.001). The age variable did not show statistically significant differences (2 = 3.379; p > 0.05).

CONCLUSIONS

There is a high prevalence of eating disorders among secondary students, being more frequently among women. We think it is necessary to make preventive services task in these problems and seek positive cases.

Research on eating disorders: current status and future prospects

This report summarizes the main themes addressed at a workshop on research on eating disorders (EDs), which was hosted by the National Institute of Mental Health in December 1998. Both basic behavioral neuroscientists and clinical investigators met in an effort to integrate areas of research and foster collaborations. Considerable advances have been made in understanding the neuroendocrinological mechanisms that regulate appetite and food intake. These achievements are in sharp contrast with the limited progress in elucidating the pathogenesis of EDs and developing effective treatment and preventive interventions. Anorexia nervosa remains a highly morbid condition with the highest mortality of any other psychiatric disorder. Besides acute refeeding techniques, no specific interventions have been proven effective in changing the long-term course of anorexia nervosa. Efficacious treatments exist for bulimia nervosa, but their underutilization calls for research on translating experimental findings into clinical practice. Closer interface between neuroscientists and clinical researchers is required for advancing our understanding of ED pathogenesis and developing effective treatments. Recent studies are suggestive of a substantial genetic contribution to EDs that deserves further investigation. Finally, there is an urgent need to examine risk and protective factors for EDs, on which safe and effective prevention can be built.

Prevalence and symptomatology of comorbid obsessive-compulsive disorder among bulimic patients

This study sought to assess the prevalence and symptomatology of comorbid obsessive-compulsive disorder (OCD) among Japanese subjects who met the DSM-III-R criteria for bulimia nervosa (BN). The Structured Clinical Interview for DSM-III-R Patient Version was used to distinguish 26 BN patients with concurrent OCD from 52 BN patients without OCD. Obsessive-compulsive symptoms in BN subjects with concurrent OCD were evaluated using the Japanese version of the Yale-Brown Obsessive-Compulsive Scale. There were no differences in the prevalence of concurrent OCD between BN subjects with and without a lifetime history of anorexia nervosa. Among BN subjects with concurrent OCD, symptoms related to symmetry and order were most frequently identified, followed by contamination and aggressive obsessions, and checking and cleaning/washing compulsions. Bulimia nervosa subjects with concurrent OCD were more likely than subjects without OCD to have more severe mood and core eating disorder psychopathology. Comorbid OCD is a common phenomenon in Japanese bulimics (33%) similar to that suggested in BN subjects in the Western countries. Obsessive-compulsive symptoms related to symmetry and order were most frequently observed in BN subjects with concurrent OCD, which was a similar finding to that reported among restricting anorexic subjects.

Obsessive-compulsive disorder symptoms before and after recovery from bulimia nervosa

OBJECTIVE

Obsessive-compulsive disorder (OCD) symptoms are common in people who are ill with bulimia nervosa. However, little is known about whether OCD symptoms persist after long-term recovery from bulimia.

METHOD

Thirty-one female patients with bulimia nervosa, 29 women who had been recovered from bulimia for more than 1 year, and 19 healthy female comparison subjects completed the Yale-Brown Obsessive Compulsive Scale, which measures OCD-like symptoms. Items related to symptoms of core eating disorders were omitted from the Yale-Brown scale.

RESULTS

The Yale-Brown scale scores of the women with bulimia (mean = 13.1, SD = 10.6) and those who had recovered from bulimia (mean = 7.9, SD = 7.0) were significantly higher than the scores of the normal comparison subjects (mean = 1.9, SD = 2.6). Women with bulimia and those who had recovered from bulimia had similar Yale-Brown scale scores and endorsed similar Yale-Brown scale target symptoms, such as obsessions related to symmetry and exactness.

CONCLUSIONS

OCD symptoms persist after recovery from bulimia. Moreover, the types of OCD symptoms experienced by bulimia patients do not vary dramatically with improvement in bulimic symptoms. Persistent OCD symptoms after recovery from bulimia raise the possibility that these behaviors are trait-related and contribute to the pathogenesis of bulimia.

A comparison of clinical features among Japanese eating-disordered women with obsessive-compulsive disorder

Clinical features, such as obsessive-compulsive disorder (OCD) symptoms, were investigated in Japanese women with DSM-III-R eating disorders (EDs) and concurrent OCD in comparison to age-matched women with OCD. Sixteen women with restricting anorexia nervosa (AN), 16 with bulimia nervosa (BN), and 16 with both AN and BN (BAN) showed commonality in a more elevated prevalence of OCD symptoms of symmetry and order compared with 18 OCD women. Among the personality disorders (PDs), likewise, obsessive-compulsive PD (OCPD) was more prevalent in each ED group compared with the OCD group. However, aggressive obsessions were more common in both BN and BAN subjects compared with AN subjects. Subjects with bulimic symptoms were also distinguished from AN subjects by impulsive features in behavior and personality. Thus, an elevated prevalence of aggressive obsessions along with an admixture of impulsive and compulsive features specifically characterized the clinical features of bulimic subjects with OCD.