How are depression and bulimia related?

[The affective pathology in patients with adolescent bulimia nervosa]

AIM

To investigate affective pathology in patients with adolescent bulimia nervosa (BN) and to analyze comorbid mutual influences of these clinical entities.

MATERIAL AND METHODS

A sample consisted of 52 young female patients, aged from 13.9 to 17.4 years, who simultaneously meet ICD-10 criteria of F50.2 - typical BN and F30-F39 - mood disorders. The Eating Attitudes Test (EAT-26) and the Beck Depression Inventory were used for psychometric assessment. Duration of follow-up ranged from 1 to 7 years.

RESULTS AND CONCLUSION

The common forms of affective disorders comorbid with adolescent BN were dysthymia and bipolar affective disorder (BAD) type II. Less often BN manifested in association with psychogenic endoform depressions. And the less typical was comorbidity of BN with endogenous recurrent unipolar depression. The normalization of mood and transition depression to hypomania contributed to the remission of eating disorders. Worst clinical and social outcome was detected in patients with long-term persistent hypothymia caused by dysthymia or protracted depressive episodes of recurrent depressive disorder. A more favorable outcome was seen in patients with alternation of depression and hypomania in the structure of the BAD type II and the best outcome in patients with single episode of psychogenic endoform depression.

Changes in internal states across the binge-vomit cycle in bulimia nervosa

While there is considerable evidence that bulimic behaviors serve the function of modifying internal states (e.g., satiety, mood), there is less clarity over the roles of the different behaviors across the binge-purge cycle. The present study examines the impact of bingeing and vomiting upon these internal states at different time points, and evaluates the potential reinforcement of those behaviors by the changes in internal states. Twenty-three women with diagnoses of bulimia nervosa completed a diary of all binge-vomit episodes over the course of 7 days, rating their internal states (satiety, negative mood, positive mood) at four time points during each episode. There were substantial changes across the cycle in levels of hunger, fullness, guilt/shame, anxiety/worry, and happiness/relief, but not in other states. The changes indicate that the binge-vomit cycle is maintained by the effects of both behaviors, but that the vomiting behavior evokes the strongest pattern of reinforcement. Further research is needed to determine the levels of internal states during the binge itself.

Assessment of eating disorders: review and recommendations for clinical use

Practitioners have come under increasing pressure to provide objective data on assessment and treatment outcome of clients. This article provides a brief summary of assessment of eating disorders for the practicing clinician, with an emphasis on well-validated assessment instruments. The critical domains that should be covered in a thorough assessment of eating disorders are reviewed, as are some shortcomings in the current assessment literature, and also discussed is which assessment instruments for the eating disorders are most useful in a clinical context. Using well-validated, standardized assessment instruments in all phases of the treatment process is a critical part of justifying a treatment plan and providing objective data on client progress and outcome.

Mood and forbidden foods' influence on perceptions of binge eating

This study consists of two experiments investigating the effects of induced mood and food type on perceptions of eating in imagined and real eating situations. A total of 212 female undergraduates representing the continuum of bulimic symptomatology were induced with either elated or depressed moods using a standardized mood-induction procedure. They were then either asked to imagine themselves in a situation with either forbidden or non-forbidden foods (Experiment 1) or else were presented with a buffet of forbidden or non-forbidden foods and asked to eat (Experiment 2). Participants subsequently reported their perception of their eating behavior (i.e., amount of control, meal rating: from a snack to a binge; and meal feeling: from great to bad). Results revealed limited support for affect regulation models of bulimia nervosa when the participants consumed food, but no support for the theory when they imagined eating. Conversely, forbidden foods were found to influence perceptions in the imagined eating situation, but not when the participants ate. Implications of these results are discussed.

Borderline personality, impulsiveness, and platelet monoamine measures in bulimia nervosa and recurrent suicidal behavior

This study examined the relationship between borderline and impulsive personality traits on the one hand, and monoamine function on the other in 15 women with bulimia nervosa and 15 women with recurrent suicidal behavior. Platelet serotonin (5-HT) and platelet monoamine oxidase (MAO) activity were used as peripheral measures of monoaminergic function. All suicide attempters were diagnosed as having a borderline personality disorder, whereas this diagnosis was less frequent in bulimics. Bulimics with borderline comorbidity resembled recurrent suicide attempters with borderline personality disorder more closely in both psychological (anger, impulsive behavior) and biochemical characteristics (platelet 5-HT) than bulimics without borderline personality disorder. Platelet 5-HT was higher in patients with borderline personality than in normal female controls and was positively correlated with the disposition to experience anger. Impulsive personality traits were consistently negatively correlated with platelet MAO activity. Our findings support the subdivision of bulimics according to the presence of borderline or "multi-impulsive" personality disorder.

Selecting control groups for studies of familial aggregation of disease

In genetic-epidemiologic studies to determine the association between the disease status of family members, this association is measured by comparing rates of the disease in relatives of probands (index cases) with the disease, with the rates of the disease among individuals in a control group. Either of two types of control groups are generally used: (1) a control group consisting of a random sample from the population or the entire population if available or (2) a control group consisting of relatives of individuals without the disease under study. We examine the advantages and disadvantages of using these different types of control groups. We show two major results for family studies: (1) when there are no other factors associated with the disease status of an individual other than the disease status of a family member, both types of control groups will give a valid test of the null hypothesis of no familial aggregation. However, tests using a population control group will always be less efficient statistically, than those performed with a control group of relatives of probands without the disease under study, the degree of efficiency decreasing with increasing population prevalence of the disease. (2) When factors other than the disease status of a family member are also associated with the disease status of an individual, if this factor is a proband characteristic (which is not shared by relatives) population control groups cannot be adjusted to eliminate possible bias due to the potential confounding effect of this factor (unlike control groups consisting of relatives of probands without the disorder).

Pharmacotherapy of the eating disorders: a commentary

During the last 10 yr, evidence has accumulated which indicates that the eating disorders of bulimia and anorexia nervosa (BN and AN) may be differentially affected by pharmacological treatment. Although the efficacy of drug treatment alone (relative to nonpharmacological approaches) has been debated, there is support for the generalization that all types of antidepressant medications have proven efficacious for bulimia but not for anorexia. These clinical observations are consistent with an extensive body of research concerning the regulation of ingestion, which indicates that the neurotransmitter serotonin plays an important role in mediating satiety. Such considerations have led to the "serotonin-hypothesis of bulimia," which postulates that BN represents an underlying "hyposerotonergic" condition and, conversely, that AN represents a "hyperserotonergic" state. Recently, however, two independent studies have shown that the antidepressant fluoxetine, which selectively blocks the synaptic re-uptake of serotonin, provided significant therapeutic benefit for anorexic patients. The implications of these apparently anomalous results for the "serotonin-hypothesis of BN" are discussed in an attempt to gain insight into the present pharmacotherapy of the eating disorders.

Alexithymia, depression, and treatment outcome in bulimia nervosa

Disturbances in emotional awareness, sometimes referred to as alexithymia, have been hypothesized to contribute to the development of binge/purge symptoms among women with bulimia nervosa (BN) and/or are considered secondary to the state of depression and/or disordered eating. The present study was designed to assess alexithymia among women with BN, to evaluate the interrelationship between alexithymia, depression, and somatic symptoms, and to determine whether an intensive group psychotherapy program contributes to a reduction in the degree of alexithymia. Thirty-one of 50 BN women (62%) who completed The Toronto Hospital Day Hospital Program for Eating Disorders (DHP) were administered pretreatment and posttreatment questionnaires. Findings from this clinical sample were compared with those from 20 non-eating-disordered women who completed the same battery. Using the Toronto Alexithymia Scale (TAS), significantly more BN women were alexithymic at pretreatment (61.3%) and post-treatment (32.3%) than in the comparison group (5.0%), even when depression was controlled for. At discharge, abstinence from binge/purge episodes was associated with a significant reduction in alexithymia, although there was a significant correlation between TAS scores, depression, and vomit frequency. Alexithymia among BN women is not simply a concomitant of disordered eating. Its partial reversibility following an intensive psychotherapy program may be a direct effect of the treatment and/or may be secondary to a reduction in depressive and/or binge/purge symptoms.

A study of the relation between eating disorder and death concern

The relationship between eating disorder and various components of death orientation (fear, anxiety, acceptance and concern) was examined, taking into account the level of depression in patient samples as well as elements of religiosity. The results were not able to support more than a very modest relationship between eating disorder and death orientation. Eating disorder patients could not be distinguished from other clinical controls, nor did anorexia nervosa patients differ from other eating disorder patients in this respect. Beck and Beck [20] depression scores were higher in the non eating disordered clinical sample than in the eating disorder group, and death concern was shown to be related to the severity of depression. Religiosity did not appear important when indices of religiosity were considered, but did emerge as an important factor in the "free information" provided by participants.

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

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

Seasonal mood symptoms in bulimia nervosa and seasonal affective disorder

Mood and appetite disturbances are commonly found in bulimia nervosa and seasonal affective disorder (SAD). To investigate seasonality of mood symptoms, we administered the Seasonal Pattern Assessment Questionnaire (SPAQ) to 38 consecutive bulimic patients, 38 age- and sex-matched SAD patients, and 25 age- and sex-matched normal controls. The SPAQ is a reliable, retrospective, self-rated questionnaire that assesses seasonal changes in mood, sleep, weight, and social activity. The SAD patients had significantly higher Global Seasonality Scores (GSS) than the bulimic patients, who had higher scores than the control group (F = 78.6, df = 2.98, P less than .0001). Forty-two percent of bulimics met case-finding SPAQ criteria for SAD, compared with none of the control group (chi 2 = 14.1, df = 1, P less than .0005). These data suggest that a significant number of unselected bulimic patients have seasonal mood symptoms as severe as that seen in SAD. We propose that a common neurobiologic abnormality, such as serotonergic dysfunction, may underlie the common symptoms found in bulimia and SAD.

Eating disorders and depression: is there a serotonin connection?

Central serotonin pathways modulate eating patterns, and may also participate in the regulation of behavioral impulsivity and mood. Recent studies lend support to the hypothesis that impaired postingestive satiety in bulimia nervosa is associated with reduced hypothalamic serotonergic responsiveness. Serotonin dysregulation has been implicated in major depression, and may play a role in the increased prevalence of depressive episodes in patients with eating disorders. This review compares evidence for alterations in central serotonin regulation in patients with anorexia nervosa, bulimia nervosa, and depression. It is proposed that impaired synaptic transmission in functionally distinct serotonin pathways may result in concurrent or sequential periods of binge eating, behavioral impulsivity, and depression in patients with eating disorders.

Prevalence of eating disorders in the psychiatric emergency room

A random sample of 143 patients from a centralized psychiatric emergency service with a catchment area of one million people was studied. A two-stage interview was conducted for diagnosis of DSM-III-R eating disorders. Of those reporting active bingeing, 14.5% were men, and 22.4% were women. No cases of anorexia nervosa were discovered. Bulimia nervosa was diagnosed in 3.0% of the women and 2.6% of the men. Race and marital status were unrelated to bingeing or to any eating disorder diagnosis. Many patients never had discussed their eating behaviors before with a therapist.

Comparison of regional brain metabolism in bulimia nervosa and affective disorder assessed with positron emission tomography

Women with bulimia often present with symptoms of depression in addition to bingeing and purging behavior. Brain metabolism in eight women with bulimia nervosa was compared to that in eight women with major affective disorder and eight normal women, using positron emission tomography and 18-fluoro-2-deoxyglucose. Normal women have higher right than left cortical metabolic rates and active basal ganglia. Bulimics lost the normal right activation in some areas, but maintained basal ganglia activity. Depressives retained right hemisphere activation, but had decreased metabolism in basal ganglia. This suggests that although women with bulimia frequently present with symptoms of depression, the pathophysiologic changes associated with bulimia differ from major effective disorder.