Identification of Novel, Replicable Genetic Risk Loci for Suicidal Thoughts and Behaviors Among US Military Veterans

Importance

Suicide is a leading cause of death; however, the molecular genetic basis of suicidal thoughts and behaviors (SITB) remains unknown.

Objective

To identify novel, replicable genomic risk loci for SITB.

Design, Setting, and Participants

This genome-wide association study included 633 778 US military veterans with and without SITB, as identified through electronic health records. GWAS was performed separately by ancestry, controlling for sex, age, and genetic substructure. Cross-ancestry risk loci were identified through meta-analysis. Study enrollment began in 2011 and is ongoing. Data were analyzed from November 2021 to August 2022.

Main Outcome and Measures

SITB.

Results

A total of 633 778 US military veterans were included in the analysis (57 152 [9%] female; 121 118 [19.1%] African ancestry, 8285 [1.3%] Asian ancestry, 452 767 [71.4%] European ancestry, and 51 608 [8.1%] Hispanic ancestry), including 121 211 individuals with SITB (19.1%). Meta-analysis identified more than 200 GWS (P < 5 × 10-8) cross-ancestry risk single-nucleotide variants for SITB concentrated in 7 regions on chromosomes 2, 6, 9, 11, 14, 16, and 18. Top single-nucleotide variants were largely intronic in nature; 5 were independently replicated in ISGC, including rs6557168 in ESR1, rs12808482 in DRD2, rs77641763 in EXD3, rs10671545 in DCC, and rs36006172 in TRAF3. Associations for FBXL19 and AC018880.2 were not replicated. Gene-based analyses implicated 24 additional GWS cross-ancestry risk genes, including FURIN, TSNARE1, and the NCAM1-TTC12-ANKK1-DRD2 gene cluster. Cross-ancestry enrichment analyses revealed significant enrichment for expression in brain and pituitary tissue, synapse and ubiquitination processes, amphetamine addiction, parathyroid hormone synthesis, axon guidance, and dopaminergic pathways. Seven other unique European ancestry-specific GWS loci were identified, 2 of which (POM121L2 and METTL15/LINC02758) were replicated. Two additional GWS ancestry-specific loci were identified within the African ancestry (PET112/GATB) and Hispanic ancestry (intergenic locus on chromosome 4) subsets, both of which were replicated. No GWS loci were identified within the Asian ancestry subset; however, significant enrichment was observed for axon guidance, cyclic adenosine monophosphate signaling, focal adhesion, glutamatergic synapse, and oxytocin signaling pathways across all ancestries. Within the European ancestry subset, genetic correlations (r > 0.75) were observed between the SITB phenotype and a suicide attempt-only phenotype, depression, and posttraumatic stress disorder. Additionally, polygenic risk score analyses revealed that the Million Veteran Program polygenic risk score had nominally significant main effects in 2 independent samples of veterans of European and African ancestry.

Conclusions and Relevance

The findings of this analysis may advance understanding of the molecular genetic basis of SITB and provide evidence for ESR1, DRD2, TRAF3, and DCC as cross-ancestry candidate risk genes. More work is needed to replicate these findings and to determine if and how these genes might impact clinical care.

Common Genetic Variation and Age of Onset of Anorexia Nervosa

Background

Genetics and biology may influence the age of onset of anorexia nervosa (AN). The aims of this study were to determine whether common genetic variation contributes to age of onset of AN and to investigate the genetic associations between age of onset of AN and age at menarche.

Methods

A secondary analysis of the Psychiatric Genomics Consortium genome-wide association study (GWAS) of AN was performed, which included 9335 cases and 31,981 screened controls, all from European ancestries. We conducted GWASs of age of onset, early-onset AN (<13 years), and typical-onset AN, and genetic correlation, genetic risk score, and Mendelian randomization analyses.

Results

Two loci were genome-wide significant in the typical-onset AN GWAS. Heritability estimates (single nucleotide polymorphism-h 2) were 0.01-0.04 for age of onset, 0.16-0.25 for early-onset AN, and 0.17-0.25 for typical-onset AN. Early- and typical-onset AN showed distinct genetic correlation patterns with putative risk factors for AN. Specifically, early-onset AN was significantly genetically correlated with younger age at menarche, and typical-onset AN was significantly negatively genetically correlated with anthropometric traits. Genetic risk scores for age of onset and early-onset AN estimated from independent GWASs significantly predicted age of onset. Mendelian randomization analysis suggested a causal link between younger age at menarche and early-onset AN.

Conclusions

Our results provide evidence consistent with a common variant genetic basis for age of onset and implicate biological pathways regulating menarche and reproduction.

Long-term outcome in males with anorexia nervosa: A prospective, sex-matched study

OBJECTIVE

The objective of this study is to report on the 5.5-years outcome of anorexia nervosa (AN) in male adolescent inpatients and compare it to the outcome of female adolescent inpatients with AN.

METHOD

Diagnostic eating disorder outcome was assessed by the Structured Inventory of Anorexic and Bulimic Syndromes (DSM-IV) in 20 males and 20 females matched for AN diagnosis, age at treatment, and length of follow-up. For documentation, follow-up scores of the Eating Disorder Inventory and the Brief Symptom Inventory are reported.

RESULTS

Diagnostic outcome did not differ between sexes. Four male and six female participants had AN at follow-up. One male and four females had crossed to bulimia nervosa, and five males and three females to eating disorder not otherwise specified. Remission was found in 10 males and 7 females. Effect sizes were mostly small. At follow-up females had higher scores than males with large effect sizes for drive for thinness (Cohen's d = 0.86) and body dissatisfaction (d = 1.07).

DISCUSSION

Few significant sex differences were found. Additional research involving larger samples of males and a broader range of assessed outcomes (e.g., drive for muscularity) in both sexes is urgently needed.

Dissecting the Shared Genetic Architecture of Suicide Attempt, Psychiatric Disorders, and Known Risk Factors

BACKGROUND

Suicide is a leading cause of death worldwide, and nonfatal suicide attempts, which occur far more frequently, are a major source of disability and social and economic burden. Both have substantial genetic etiology, which is partially shared and partially distinct from that of related psychiatric disorders.

METHODS

We conducted a genome-wide association study (GWAS) of 29,782 suicide attempt (SA) cases and 519,961 controls in the International Suicide Genetics Consortium (ISGC). The GWAS of SA was conditioned on psychiatric disorders using GWAS summary statistics via multitrait-based conditional and joint analysis, to remove genetic effects on SA mediated by psychiatric disorders. We investigated the shared and divergent genetic architectures of SA, psychiatric disorders, and other known risk factors.

RESULTS

Two loci reached genome-wide significance for SA: the major histocompatibility complex and an intergenic locus on chromosome 7, the latter of which remained associated with SA after conditioning on psychiatric disorders and replicated in an independent cohort from the Million Veteran Program. This locus has been implicated in risk-taking behavior, smoking, and insomnia. SA showed strong genetic correlation with psychiatric disorders, particularly major depression, and also with smoking, pain, risk-taking behavior, sleep disturbances, lower educational attainment, reproductive traits, lower socioeconomic status, and poorer general health. After conditioning on psychiatric disorders, the genetic correlations between SA and psychiatric disorders decreased, whereas those with nonpsychiatric traits remained largely unchanged.

CONCLUSIONS

Our results identify a risk locus that contributes more strongly to SA than other phenotypes and suggest a shared underlying biology between SA and known risk factors that is not mediated by psychiatric disorders.

[Eating and feeding disorders : New developments]

An overview of eating and feeding disorders according to the future criteria of the International Classification of Diseases (ICD-11) is presented, including information on differential diagnosis, epidemiology, etiology, pathogenesis as well as therapy. Binge-eating disorder is new and the most frequent eating disorder. While anorexia nervosa and bulimia nervosa mostly affect women, the gender ratio in binge-eating disorder is more balanced. Concerning etiology, socio-cultural, biological and psychological factors are discussed. Cognitive behavioral psychotherapy is the best-validated treatment for all three eating disorders. According to the German guidelines for treatment (2019), focal psychodynamic psychotherapy is also a treatment option for anorexia nervosa. Evidence for the positive effect of psychopharmacologic drugs in the treatment of anorexia nervosa is still lacking. Fluoxetine has been shown to have a limited effect in the treatment of bulimia nervosa.

How precisely can psychotherapists predict the long-term outcome of anorexia nervosa and bulimia nervosa at the end of inpatient treatment?

OBJECTIVE

To assess the ability of psychotherapists to predict the future outcome for inpatients with anorexia nervosa (AN) and bulimia nervosa (BN).

METHOD

Psychotherapists rated the prognosis of the patient's eating disorder on a five point Likert scale on several dimensions at the end of inpatient treatment. Actual outcome was assessed about 10 years after treatment. The sample comprised 1,065 patients treated for AN, and 1,192 patients treated for BN.

RESULTS

Psychotherapists' rating of their patient's prognosis was not better than chance for good outcome in AN and BN and for poor outcome in BN. Prediction of poor outcome in AN was somewhat better with approximately two thirds of correct predictions. In logistic regression analysis, psychotherapists' rating of the patients' prognosis for AN contributed to the explained variance of long-term outcome, increasing the variance explained from 7% (by conventional predictors) to 8% after including psychotherapists' prognosis. In BN, there was no significant contribution of psychotherapists' prognosis to overall prediction.

DISCUSSION

Our current knowledge of risk and protective factors for the course of eating disorders is unsatisfying. More specialized research is urgently needed.

Long-term outcomes in treated males with anorexia nervosa and bulimia nervosa-A prospective, gender-matched study

OBJECTIVE

We report on the long-term outcome of males compared to females treated for anorexia nervosa (AN) or bulimia nervosa (BN).

METHODS

A total of 119 males with AN and 60 males with BN were reassessed 5.8 ± 4.6 and 7.5 ± 5.9 years (respectively) after treatment and compared to matched female patients.

RESULTS

At follow-up, males with AN had a higher body weight than females. For AN, remission rates (40% males vs. 41% females) did not differ at follow-up. And at follow-up, more males (34%) than females (19%) had an eating disorder not otherwise specified (ED-NOS; p < .01). At follow-up of AN, there was no binge-eating disorder (BED) and obesity was rare. For BN, remission rates (44% males vs. 50% females) and frequency of AN, BN, BED and ED-NOS did not differ at follow-up. Males with AN scored lower than females at follow-up on most subscales of the Eating Disorder Inventory (EDI) and on somatization, obsessive-compulsive symptoms, and depression (Brief Symptom Inventory). Males with BN scored lower than females with BN on perfectionism and higher on interpersonal distrust (EDI) at follow-up.

DISCUSSION

Results from the scarce literature on males with ED are inconclusive regarding longer term outcome. In the present study, males with AN showed a slightly better outcome than females. In BN, outcome was about the same in males and females. According to our study, existing treatment is equally effective in both males and females. Additional research on the need of gender-specific diagnosis and therapy is required.

Mortality in males treated for an eating disorder-A large prospective study

OBJECTIVE

To report on the long-term mortality of eating disorders in male inpatients.

METHOD

Crude mortality rates (CMR) and standardized mortality ratios (SMR) were computed for a large sample of males (147 anorexia nervosa [AN], 81 bulimia nervosa [BN], 110 eating disorder not otherwise specified [ED-NOS]; DSM-IV). In addition, a survival analysis from onset of eating disorder to death or end of observation was computed.

RESULTS

CMR was 12.9% in AN, 11.1% in BN, and 6.4% in ED-NOS. Standardized mortality was significantly elevated in males with AN (SMR = 5.91; 95% confidence interval 3.56-9.23) as well as ED-NOS (SMR = 3.40; 95% confidence interval 1.37-7.01) but not in males with BN (SMR = 1.88; 95% confidence interval 0.86-3.58). Males with AN died sooner after onset of eating disorder than males with BN or ED-NOS.

DISCUSSION

Mortality in male inpatients with eating disorder is high, especially in AN. There is need for developing more effective treatments to achieve better outcome.

Genome-wide association study identifies eight risk loci and implicates metabo-psychiatric origins for anorexia nervosa

Characterized primarily by a low body-mass index, anorexia nervosa is a complex and serious illness1, affecting 0.9-4% of women and 0.3% of men2-4, with twin-based heritability estimates of 50-60%5. Mortality rates are higher than those in other psychiatric disorders6, and outcomes are unacceptably poor7. Here we combine data from the Anorexia Nervosa Genetics Initiative (ANGI)8,9 and the Eating Disorders Working Group of the Psychiatric Genomics Consortium (PGC-ED) and conduct a genome-wide association study of 16,992 cases of anorexia nervosa and 55,525 controls, identifying eight significant loci. The genetic architecture of anorexia nervosa mirrors its clinical presentation, showing significant genetic correlations with psychiatric disorders, physical activity, and metabolic (including glycemic), lipid and anthropometric traits, independent of the effects of common variants associated with body-mass index. These results further encourage a reconceptualization of anorexia nervosa as a metabo-psychiatric disorder. Elucidating the metabolic component is a critical direction for future research, and paying attention to both psychiatric and metabolic components may be key to improving outcomes.

Long-term outcome of inpatients with bulimia nervosa-Results from the Christina Barz Study

OBJECTIVE

To assess the long-term outcome and identify outcome predictors in a very large sample of inpatients treated for bulimia nervosa (BN).

METHOD

Out of a total of 2,033 patients admitted consecutively to specialized treatment, 1,351 patients (mean age at treatment 25.94) were assessed for follow-up on average 11 (SD 6) years after admission. Also a very long-term (21 years) subsample (N = 147; mean age 25.92) was defined. Bivariate and logistic regression analyses identified predictors of poor outcome.

RESULTS

For more than 70% of the patients follow-up information could be gathered. Severity of eating disorder (ED) and other symptoms decreased over time but remained higher than in healthy controls, using published normative data. Remission rate was 38% after 11 years and 42% in the subsample after 21 years. Out of the total sample of N = 2,033 patients, 49 had died (2.4%). Persistent BN was found in 14.2% and the most frequent crossover was to ED not otherwise specified. Predictors of poor outcome were fewer follow-up years, higher drive for thinness, higher age at treatment, and less global functioning.

DISCUSSION

Based on clinical indicators, patients presented with a high level of ED and psychiatric symptomatology. With less than half of the patients remitted after 22 years, efforts are needed to improve treatment outcome.

Short- and long-term outcome of males treated for anorexia nervosa: a review of the literature

PURPOSE

To give an overview of existing studies on the short- and long-term outcome for males treated for anorexia nervosa and to compare the outcome between adolescents and adults as well as between males and females.

METHODS

A systematic literature search was conducted in PubMed, PsycINFO and PSYNDEX and complemented by a manual search of the references from all relevant studies.

RESULTS

Out of 1064 search results, 18 studies met our inclusion criteria. A combined total of 1129 males of varying age groups were followed 0.5-27 years post-treatment. For 1009 individuals, only vital status was ascertained. Length of follow-up and outcome definitions varied considerably. Limited data-especially in adults-prevented adequate age comparisons. In both adolescents and adults outcome and mortality differed widely across studies with no firm evidence for gender differences. Outcome in mixed samples of adolescents and adults was inconsistent. Studies rarely compared the genders statistically, and when they did, the results were nonsignificant.

CONCLUSIONS

Knowledge on the outcome of males treated for anorexia nervosa is scarce. Only few studies comprising insufficient numbers of males exist. Results based on these findings are inconclusive and in part contradicting. Further research is needed, including large sample sizes of reliably diagnosed males, adequate follow-up intervals, follow-up assessments with carefully defined outcome criteria, and comparisons to matched female patient samples.

LEVEL OF EVIDENCE

Level I, Systematic review.

Associations between dimensions of anorexia nervosa and obsessive-compulsive disorder: An examination of personality and psychological factors in patients with anorexia nervosa

OBJECTIVE

Anorexia nervosa (AN) and obsessive-compulsive disorder (OCD) are highly comorbid. However, the factors that account for this comorbidity are poorly understood. We examined the core dimensions of AN and OCD and psychological and personality factors shared by both disorders.

METHOD

In path analyses (N = 732 women with either current AN or recovered from AN), we examined which factors were uniquely and independently associated with the core dimensions of AN and OCD. We also examined recovery from AN as a moderator.

RESULTS

When individuals with AN reported greater concern over mistakes, they endorsed more severity in both AN and OCD core dimensions. These unique associations existed above and beyond all other transdiagnostic personality and psychological factors and regardless of AN recovery status.

CONCLUSIONS

Concern over mistakes partially accounts for severity in the core dimensions of both AN and OCD. Concern over mistakes may represent an important target in the aetiology of AN and OCD.

The role of leptin, melanocortin, and neurotrophin system genes on body weight in anorexia nervosa and bulimia nervosa

OBJECTIVE

Although low weight is a key factor contributing to the high mortality in anorexia nervosa (AN), it is unclear how AN patients sustain low weight compared with bulimia nervosa (BN) patients with similar psychopathology. Studies of genes involved in appetite and weight regulation in eating disorders have yielded variable findings, in part due to small sample size and clinical heterogeneity. This study: (1) assessed the role of leptin, melanocortin, and neurotrophin genetic variants in conferring risk for AN and BN; and (2) explored the involvement of these genes in body mass index (BMI) variations within AN and BN.

METHOD

Our sample consisted of 745 individuals with AN without a history of BN, 245 individuals with BN without a history of AN, and 321 controls. We genotyped 20 markers with known or putative function among genes selected from leptin, melanocortin, and neurotrophin systems.

RESULTS

There were no significant differences in allele frequencies among individuals with AN, BN, and controls. AGRP rs13338499 polymorphism was associated with lowest illness-related BMI in those with AN (p = 0.0013), and NTRK2 rs1042571 was associated with highest BMI in those with BN (p = 0.0018).

DISCUSSION

To our knowledge, this is the first study to address the issue of clinical heterogeneity in eating disorder genetic research and to explore the role of known or putatively functional markers in genes regulating appetite and weight in individuals with AN and BN. If replicated, our results may serve as an important first step toward gaining a better understanding of weight regulation in eating disorders.

Evidence for the role of EPHX2 gene variants in anorexia nervosa

Anorexia nervosa (AN) and related eating disorders are complex, multifactorial neuropsychiatric conditions with likely rare and common genetic and environmental determinants. To identify genetic variants associated with AN, we pursued a series of sequencing and genotyping studies focusing on the coding regions and upstream sequence of 152 candidate genes in a total of 1205 AN cases and 1948 controls. We identified individual variant associations in the Estrogen Receptor-ß (ESR2) gene, as well as a set of rare and common variants in the Epoxide Hydrolase 2 (EPHX2) gene, in an initial sequencing study of 261 early-onset severe AN cases and 73 controls (P=0.0004). The association of EPHX2 variants was further delineated in: (1) a pooling-based replication study involving an additional 500 AN patients and 500 controls (replication set P=0.00000016); (2) single-locus studies in a cohort of 386 previously genotyped broadly defined AN cases and 295 female population controls from the Bogalusa Heart Study (BHS) and a cohort of 58 individuals with self-reported eating disturbances and 851 controls (combined smallest single locus P<0.01). As EPHX2 is known to influence cholesterol metabolism, and AN is often associated with elevated cholesterol levels, we also investigated the association of EPHX2 variants and longitudinal body mass index (BMI) and cholesterol in BHS female and male subjects (N=229) and found evidence for a modifying effect of a subset of variants on the relationship between cholesterol and BMI (P<0.01). These findings suggest a novel association of gene variants within EPHX2 to susceptibility to AN and provide a foundation for future study of this important yet poorly understood condition.

Primary amenorrhea in anorexia nervosa: impact on characteristic masculine and feminine traits

Animal studies indicate that gonadal hormones at puberty have an effect on the development of masculine and feminine traits. However, it is unknown whether similar processes occur in humans. We examined whether women with anorexia nervosa (AN), who often experience primary amenorrhea, exhibit attenuated feminization in their psychological characteristics in adulthood due to the decrease/absence of gonadal hormones at puberty. Women with AN were compared on a number of psychological characteristics using general linear models on the basis of the presence/absence of primary amenorrhea. Although women with primary amenorrhea exhibited lower anxiety scores than those without primary amenorrhea, in general, results did not provide evidence of attenuated feminization in women with AN with primary amenorrhea. Future research should utilize novel techniques and direct hormone measurement to explore the effects of pubertal gonadal hormones on masculine and feminine traits.

Factors associated with recovery from anorexia nervosa

Previous studies of prognostic factors of anorexia nervosa (AN) course and recovery have followed clinical populations after treatment discharge. This retrospective study examined the association between prognostic factors--eating disorder features, personality traits, and psychiatric comorbidity--and likelihood of recovery in a large sample of women with AN participating in a multi-site genetic study. The study included 680 women with AN. Recovery was defined as the offset of AN symptoms if the participant experienced at least one year without any eating disorder symptoms of low weight, dieting, binge eating, and inappropriate compensatory behaviors. Participants completed a structured interview about eating disorders features, psychiatric comorbidity, and self-report measures of personality. Survival analysis was applied to model time to recovery from AN. Cox regression models were used to fit associations between predictors and the probability of recovery. In the final model, likelihood of recovery was significantly predicted by the following prognostic factors: vomiting, impulsivity, and trait anxiety. Self-induced vomiting and greater trait anxiety were negative prognostic factors and predicted lower likelihood of recovery. Greater impulsivity was a positive prognostic factor and predicted greater likelihood of recovery. There was a significant interaction between impulsivity and time; the association between impulsivity and likelihood of recovery decreased as duration of AN increased. The anxiolytic function of some AN behaviors may impede recovery for individuals with greater trait anxiety.

Temporal sequence of comorbid alcohol use disorder and anorexia nervosa

Women with eating disorders have a significantly higher prevalence of substance use disorders than the general population. The goal of the current study was to assess the temporal pattern of comorbid anorexia nervosa (AN) and alcohol use disorder (AUD) and the impact this ordering has on symptomatology and associated features. Women were placed into one of three groups based on the presence or absence of comorbid AUD and the order of AN and AUD onset in those with both disorders: (1) AN Only, (2) AN First, and (3) AUD First. The groups were compared on psychological symptoms and personality characteristics often associated with AN, AUD, or both using general linear models. Twenty-one percent of women (n=161) with AN reported a history of AUD with 115 reporting AN onset first and 35 reporting AUD onset first. Women with binge-eating and/or purging type AN were significantly more likely to have AUD. In general, differences were found only between women with AN Only and women with AN and AUD regardless of order of emergence. Women with AN and AUD had higher impulsivity scores and higher prevalence of depression and borderline personality disorder than women with AN Only. Women with AN First scored higher on traits commonly associated with AN, whereas women with comorbid AN and AUD displayed elevations in traits more commonly associated with AUD. Results do not indicate a distinct pattern of symptomatology in comorbid AN and AUD based on the temporal sequence of the disorders.

Cholecystokinin revisited: CCK and the hunger trap in anorexia nervosa

Objective

Despite a number of studies in the past decades, the role of Cholecystokinin (CCK) in anorexia nervosa (AN) has remained uncertain. In this study a highly specific assay for the biologically active part of CCK was used in patients with bulimic as well as with the restricting type of AN who were followed over the course of weight gain.

Methods

Ten patients with restricting and 13 with bulimic AN were investigated upon admission (T0), after a weight gain of at least 2 kg on two consecutive weighting dates (T1), and during the last week before discharge (T2) from inpatient treatment in a specialized clinic. Blood samples were drawn under fasting conditions and 20 and 60 minutes following a standard meal (250 kcal). Data were compared to those of eight controls matched for sex and age. Gastrointestinal complaints of patients were measured by a questionnaire at each of the follow-up time points.

Results

At admission, AN patients exhibited CCK-levels similar to controls both prior to and after a test meal. Pre and post-meal CCK levels increased significantly after an initial weight gain but decreased again with further weight improvement. CCK release was somewhat lower in bulimic than in restricting type AN but both subgroups showed a similar profile. There was no significant association of CCK release to either initial weight or BMI, or their changes, but CCK levels at admission predicted gastrointestinal symptom improvement during therapy.

Conclusions

Normal CCK profiles in AN at admission indicates hormonal responses adapted to low food intake while change of eating habits and weight gain results in initially increased CCK release (counteracting the attempts to alter eating behavior) that returns towards normal levels with continuous therapy.

Central coherence in full recovery of anorexia nervosa

OBJECTIVE

This study examined central coherence as a possible endophenotype in a large sample of women recovered from anorexia nervosa (rec AN). Recovery was defined by considering physiological, behavioural and psychological variables.

METHOD

A total of 100 rec AN women and 100 healthy women completed the Rey Complex Figure Test, a measure for visual-spatial central coherence. The participants were matched 1:1 for age and educational level.

RESULTS

Compared with the healthy control group, the rec AN group showed better accuracy in the copy condition. There was a trend for a local strategy in the rec AN group compared with a global strategy in the healthy control group.

CONCLUSIONS

This sample of rec AN women showed no inefficiencies in global processing but a superior local processing after full recovery from AN.

Decision-making and planning in full recovery of anorexia nervosa

OBJECTIVE

Based on findings of persisting neuropsychological impairments in women recovered from anorexia nervosa (rec AN), this study examined decision-making and planning, for achieving a desired goal, as central executive functions in a large sample of rec AN. The definition of recovery included physiological, behavioral, and psychological variables.

METHOD

A total of 100 rec AN women were compared to 100 healthy women, 1:1 matched for age and educational level. Decision-making was assessed with the Iowa Gambling Task and planning with the Tower of London. Expert interviews and self-ratings were used for assessing the inclusion/exclusion criteria and control variables.

RESULTS

Compared to healthy controls, rec AN women were better in decision-making and worse in planning even after considering control variables.

DISCUSSION

This study does not support results from other studies showing that rec AN participants perform better in decision-making. Results from this study show that planning is impaired even after full recovery from AN.

Refining behavioral dysregulation in borderline personality disorder using a sample of women with anorexia nervosa

One of the primary facets of borderline personality disorder (BPD) is behavioral dysregulation, a wide array of behaviors that are difficult to control and harmful to the individual. The purpose of this study was to explore the association between BPD and a variety of dysregulated behaviors, some of which have received little empirical attention. Using a large sample of individuals diagnosed with anorexia nervosa, 41 individuals diagnosed with BPD were compared to the rest of the sample on the presence of dysregulated behaviors using logistic regression analyses. Anorexia nervosa subtypes, age, and other Cluster B personality disorders were used as covariates. Results support an association between BPD and alcohol misuse, hitting someone/breaking things, provoking fights/arguments, self-injury, overdosing, street drug use, binge-eating, impulsive spending, shoplifting/stealing, and risky sexual behaviors. Differences between dichotomous and continuous measures of BPD yielded somewhat different results. Information on co-occurring anorexia nervosa and BPD was generated.

An examination of early childhood perfectionism across anorexia nervosa subtypes

OBJECTIVE

To examine childhood perfectionism in anorexia nervosa (AN) restricting (RAN), purging (PAN), and binge eating with or without purging (BAN) subtypes.

METHOD

The EATATE, a retrospective assessment of childhood perfectionism, and the eating disorder inventory (EDI-2) were administered to 728 AN participants.

RESULTS

EATATE responses revealed general childhood perfectionism, 22.3% of 333 with RAN, 29.2% of 220 with PAN, and 24.8% of 116 with BAN; school work perfectionism, 31.2% with RAN, 30.4% with PAN, and 24.8% with BAN; childhood order and symmetry, 18.7% with RAN, 21.7% with PAN, and 17.8% with BAN; and global childhood rigidity, 42.6% with RAN, 48.3% with PAN and 48.1% with BAN. Perfectionism preceded the onset of AN in all subtypes. Significant associations between EDI-2 drive for thinness and body dissatisfaction were present with four EATATE subscales.

DISCUSSION

Global childhood rigidity was the predominate feature that preceded all AN subtypes. This may be a risk factor for AN.

Understanding the association of impulsivity, obsessions, and compulsions with binge eating and purging behaviours in anorexia nervosa

OBJECTIVE

To further refine our understanding of impulsivity, obsessions, and compulsions in anorexia nervosa (AN) by isolating which behaviours--binge eating, purging, or both--are associated with these features.

METHODS

We conducted regression analyses with binge eating, purging, and the interaction of binge eating with purging as individual predictors of scores for impulsivity, obsessions, and compulsions in two samples of women with AN (n = 1373).

RESULTS

Purging, but not binge eating, was associated with higher scores on impulsivity, obsessions, and compulsions. Purging was also associated with worst eating rituals and with worst eating preoccupations.

CONCLUSION

Our results suggest that purging, compared with binge eating, may be a stronger correlate of impulsivity, obsessions, and compulsions in AN.

Genetic association of recovery from eating disorders: the role of GABA receptor SNPs

Follow-up studies of eating disorders (EDs) suggest outcomes ranging from recovery to chronic illness or death, but predictors of outcome have not been consistently identified. We tested 5151 single-nucleotide polymorphisms (SNPs) in approximately 350 candidate genes for association with recovery from ED in 1878 women. Initial analyses focused on a strictly defined discovery cohort of women who were over age 25 years, carried a lifetime diagnosis of an ED, and for whom data were available regarding the presence (n=361 ongoing symptoms in the past year, ie, 'ill') or absence (n=115 no symptoms in the past year, ie, 'recovered') of ED symptoms. An intronic SNP (rs17536211) in GABRG1 showed the strongest statistical evidence of association (p=4.63 × 10(-6), false discovery rate (FDR)=0.021, odds ratio (OR)=0.46). We replicated these findings in a more liberally defined cohort of women age 25 years or younger (n=464 ill, n=107 recovered; p=0.0336, OR=0.68; combined sample p=4.57 × 10(-6), FDR=0.0049, OR=0.55). Enrichment analyses revealed that GABA (γ-aminobutyric acid) SNPs were over-represented among SNPs associated at p<0.05 in both the discovery (Z=3.64, p=0.0003) and combined cohorts (Z=2.07, p=0.0388). In follow-up phenomic association analyses with a third independent cohort (n=154 ED cases, n=677 controls), rs17536211 was associated with trait anxiety (p=0.049), suggesting a possible mechanism through which this variant may influence ED outcome. These findings could provide new insights into the development of more effective interventions for the most treatment-resistant patients.

Retrospective maternal report of early eating behaviours in anorexia nervosa

This exploratory study assessed whether maternal recall of childhood feeding and eating practices differed across anorexia nervosa (AN) subtypes. Participants were 325 women from the Genetics of Anorexia Nervosa study whose mothers completed a childhood feeding and eating questionnaire. Multinomial logistic regression analyses were used to predict AN subtype from measures related to childhood eating: (i) infant feeding (breastfed, feeding schedule, age of solid food introduction), (ii) childhood picky eating (picky eating before age 1 year and between ages one and five) and (iii) infant gastrointestinal problems (vomiting and colic). Results revealed no significant differences in retrospective maternal report of childhood feeding and eating practices among AN subtypes.

Association of candidate genes with phenotypic traits relevant to anorexia nervosa

This analysis is a follow-up to an earlier investigation of 182 genes selected as likely candidate genetic variations conferring susceptibility to anorexia nervosa (AN). As those initial case-control results revealed no statistically significant differences in single nucleotide polymorphisms, herein, we investigate alternative phenotypes associated with AN. In 1762 females, using regression analyses, we examined the following: (i) lowest illness-related attained body mass index; (ii) age at menarche; (iii) drive for thinness; (iv) body dissatisfaction; (v) trait anxiety; (vi) concern over mistakes; and (vii) the anticipatory worry and pessimism versus uninhibited optimism subscale of the harm avoidance scale. After controlling for multiple comparisons, no statistically significant results emerged. Although results must be viewed in the context of limitations of statistical power, the approach illustrates a means of potentially identifying genetic variants conferring susceptibility to AN because less complex phenotypes associated with AN are more proximal to the genotype and may be influenced by fewer genes.

Absence of association between specific common variants of the obesity-related FTO gene and psychological and behavioral eating disorder phenotypes

Extensive population-based genome-wide association studies have identified an association between the FTO gene and BMI; however, the mechanism of action is still unknown. To determine whether FTO may influence weight regulation through psychological and behavioral factors, seven single-nucleotide polymorphisms (SNPs) of the FTO gene were genotyped in 1,085 individuals with anorexia nervosa (AN) and 677 healthy weight controls from the international Price Foundation Genetic Studies of Eating Disorders. Each SNP was tested in association with eating disorder phenotypes and measures that have previously been associated with eating behavior pathology: trait anxiety, harm-avoidance, novelty seeking, impulsivity, obsessionality, compulsivity, and concern over mistakes. After appropriate correction for multiple comparisons, no significant associations between individual FTO gene SNPs and eating disorder phenotypes or related eating behavior pathology were identified in cases or controls. Thus, this study found no evidence that FTO gene variants associated with weight regulation in the general population are associated with eating disorder phenotypes in AN participants or matched controls.

Severity of alcohol-related problems and mortality: results from a 20-year prospective epidemiological community study

There is evidence that high alcohol use is associated with an increase in mortality. Little is known about long-term effects of problematic alcohol consumption in non-clinical (community) populations. The aim of our study was to obtain data on this and related issues in a representative rural community sample assessed longitudinally over a period of 20 years. Assessments focused on a baseline survey from 1980 to 1984 and 20-year follow-up from 2001 to 2004. Based on expert interviews and standardized self-rating scales (e.g. MALT; Munich Alcoholism Test), the following three groups were defined (a) severe alcohol problems, (b) moderate alcohol problems, and (c) no alcohol problems. Mortality and hazard rates were analyzed with logistic and Cox regression adjusted for several health risk factors. From an original community sample of 1,465 individuals, 448 were deceased at 20-year follow-up. Participation rates were high. Baseline prevalence according to the MALT was 1.6% for severe alcohol problems and 4.0% for moderate alcohol problems. Over the 20-year time span, individuals with severe alcohol problems had a significantly elevated risk for dying earlier than the group with no alcohol problems (2.4 times higher). Mortality for those with moderate alcohol problems at baseline had a non-significantly elevated 20-year mortality risk (1.5 times higher) compared to those with no alcohol problems. Cox survival analyses corroborate these findings from multiple sequential logistic regression analyses. In discussing the mortality risk of persons with alcohol problems, the severity of the alcohol problems must be taken into account.

Life beyond the eating disorder: education, relationships, and reproduction

OBJECTIVE

We investigated the sociodemographic characteristics in women with and without lifetime eating disorders.

METHOD

Participants were from a multisite international study of eating disorders (N = 2,096). Education level, relationship status, and reproductive status were examined across eating disorder subtypes and compared with a healthy control group.

RESULTS

Overall, women with eating disorders were less educated than controls, and duration of illness and age of onset were associated with educational attainment. Menstrual status was associated with both relationship and reproductive status, but eating disorder subtypes did not differ significantly from each other or from healthy controls on these dimensions.

DISCUSSION

Differences in educational attainment, relationships, and reproduction do exist in individuals with eating disorders and are differentially associated with various eating disorder symptoms and characteristics. These data could assist in educating patients and family members about long-term consequences of eating disorders.

The significance of repetitive hair-pulling behaviors in eating disorders

We studied the relation between intrusive and repetitive hair pulling, the defining feature of trichotillomania, and compulsive and impulsive features in 1,453 individuals with anorexia nervosa and bulimia nervosa. We conducted a series of regression models examining the relative influence of compulsive features associated with obsessive-compulsive disorder, compulsive features associated with eating disorders, trait features related to harm avoidance, perfectionism, and novelty seeking, and self harm. A final model with a reduced sample (n = 928) examined the additional contribution of impulsive attributes. One of 20 individuals endorsed hair pulling. Evidence of a positive association with endorsement of compulsive behavior of the obsessive-compulsive spectrum emerged. Hair pulling may be more consonant with ritualistic compulsions than impulsive urges in those with eating disorders.

Habitual starvation and provocative behaviors: two potential routes to extreme suicidal behavior in anorexia nervosa

Anorexia nervosa (AN) is perhaps the most lethal mental disorder, in part due to starvation-related health problems, but especially because of high suicide rates. One potential reason for high suicide rates in AN may be that those affected face pain and provocation on many fronts, which may in turn reduce their fear of pain and thereby increase risk for death by suicide. The purpose of the following studies was to explore whether repetitive exposure to painful and destructive behaviors such as vomiting, laxative use, and non-suicidal self-injury (NSSI) was a mechanism that linked AN-binge-purging (ANBP) subtype, as opposed to AN-restricting subtype (ANR), to extreme suicidal behavior. Study 1 utilized a sample of 787 individuals diagnosed with one or the other subtype of AN, and structural equation modeling results supported provocative behaviors as a mechanism linking ANBP to suicidal behavior. A second, unexpected mechanism emerged linking ANR to suicidal behavior via restricting. Study 2, which used a sample of 249 AN patients, replicated these findings, including the second mechanism linking ANR to suicide attempts. Two potential routes to suicidal behavior in AN appear to have been identified: one route through repetitive experience with provocative behaviors for ANBP, and a second for exposure to pain through the starvation of restricting in ANR.

Association study of 182 candidate genes in anorexia nervosa

We performed association studies with 5,151 SNPs that were judged as likely candidate genetic variations conferring susceptibility to anorexia nervosa (AN) based on location under reported linkage peaks, previous results in the literature (182 candidate genes), brain expression, biological plausibility, and estrogen responsivity. We employed a case-control design that tested each SNP individually as well as haplotypes derived from these SNPs in 1,085 case individuals with AN diagnoses and 677 control individuals. We also performed separate association analyses using three increasingly restrictive case definitions for AN: all individuals with any subtype of AN (All AN: n = 1,085); individuals with AN with no binge eating behavior (AN with No Binge Eating: n = 687); and individuals with the restricting subtype of AN (Restricting AN: n = 421). After accounting for multiple comparisons, there were no statistically significant associations for any individual SNP or haplotype block with any definition of illness. These results underscore the importance of large samples to yield appropriate power to detect genotypic differences in individuals with AN and also motivate complementary approaches involving Genome-Wide Association (GWA) studies, Copy Number Variation (CNV) analyses, sequencing-based rare variant discovery assays, and pathway-based analysis in order to make up for deficiencies in traditional candidate gene approaches to AN.

Sexual functioning in women with eating disorders

OBJECTIVE

To describe sexual functioning in women with eating disorders.

METHOD

We assessed physical intimacy, libido, sexual anxiety, partner status, and sexual relationships in 242 women from the International Price Foundation Genetic Studies relative to normative data.

RESULTS

Intercourse (55.3%), having a partner (52.7%), decreased sexual desire (66.9%), and increased sexual anxiety (59.2%) were common. Women with restricting and purging anorexia nervosa had a higher prevalence of loss of libido than women with bulimia nervosa and eating disorder not otherwise specified (75%, 74.6%, 39%, and 45.4%, respectively). Absence of sexual relationships was associated with lower minimum lifetime body mass index (BMI) and earlier age of onset; loss of libido with lower lifetime BMI, higher interoceptive awareness and trait anxiety; and sexual anxiety with lower lifetime BMI, higher harm avoidance and ineffectiveness. Sexual dysfunction in eating disorders was higher than in the normative sample.

DISCUSSION

Sexual dysfunction is common across eating disorders subtypes. Low BMI is associated with loss of libido, sexual anxiety, and avoidance of sexual relationships.

Substance use disorders in women with anorexia nervosa

OBJECTIVE

We examined prevalence of substance use disorders (SUD) in women with: (1) anorexia nervosa (AN) restricting type (RAN); (2) AN with purging only (PAN); (3) AN with binge eating only (BAN); and (4) lifetime AN and bulimia nervosa (ANBN). Secondary analyses examined SUD related to lifetime purging behavior and lifetime binge eating.

METHOD

Participants (N = 731) were drawn from the International Price Foundation Genetic Studies.

RESULTS

The prevalence of SUD differed across AN subtypes, with more in the ANBN group reporting SUD than those in the RAN and PAN groups. Individuals who purged were more likely to report substance use than those who did not purge. Prevalence of SUD differed across lifetime binge eating status.

DISCUSSION

SUD are common in AN and are associated with bulimic symptomatology. Results underscore the heterogeneity in AN, highlighting the importance of screening for SUD across AN subtypes.

Childhood anxiety associated with low BMI in women with anorexia nervosa

OBJECTIVE

Extremely low body mass index (BMI) values are associated with increased risk for death and poor long-term prognosis in individuals with anorexia nervosa (AN). The present study explores childhood personality characteristics that could be associated with the ability to attain an extremely low BMI.

METHODS

Participants were 326 women from the Genetics of Anorexia Nervosa (GAN) Study who completed the Structured Interview for Anorexia Nervosa and Bulimic Syndromes and whose mother completed the Child Behavioral Checklist and/or Revised Dimensions of Temperament Survey.

RESULTS

Children who were described as having greater fear or anxiety by their mothers attained lower BMIs during AN (p < 0.02). Path analysis in the GAN and a validation sample, Price Foundation Anorexia Nervosa Trios Study, confirmed the relation between early childhood anxiety, caloric restriction, qualitative food item restriction, excessive exercise, and low BMI. Path analysis also confirmed a relation between childhood anxiety and caloric restriction, which mediated the relation between childhood anxiety and low BMI in the GAN sample only.

CONCLUSION

Fearful or anxious behavior as a child was associated with the attainment of low BMI in AN and childhood anxiety was associated with caloric restriction. Measures of anxiety and factors associated with anxiety-proneness in childhood may index children at risk for restrictive behaviors and extremely low BMIs in AN.

From childhood to adult age: 18-year longitudinal results and prediction of the course of mental disorders in the community

OBJECTIVE

This prospective longitudinal study of a representative community sample of children and adolescents (N = 269) examined the long-term course and predictive power of psychiatric symptoms in childhood/adolescence for diagnostic outcome (ICD-10) 18 years later at adult age.

METHOD

At both cross-sectional assessments, baseline (1980-1984) and the 18-year follow-up (2001-2004), psychiatric symptoms were assessed using the 'Standardized Psychiatric Interview' (Goldberg et al. in Br J Prev Soc Med 24:18-23, 1970). At follow-up, study participants were reassessed with the standardized M-CIDI (Wittchen and Pfister in Manual und Durchführungsbeschreibung des DIA-X-M-CIDI, Swets and Zeitlinger, Frankfurt, 1997) interview.

RESULTS

The participation rate at 18-year follow-up was 82% of those alive. The frequency of clinically relevant depressive symptoms and symptoms of anxiety or phobia was considerably higher when the participants were younger (baseline assessment at childhood, adolescent age) as compared to their scores in adult age. Increased levels of somatic symptoms, fatigue, irritability, sleep disturbances, depression, anxiety and worry as well as phobic symptoms in childhood/adolescence were related to a higher risk of suffering from a psychiatric disorder in adulthood. Depressive symptoms predicted both mood disorders and substance use disorders in adulthood. Phobias predicted later anxiety disorders.

CONCLUSION

These data spanning almost two decades add significant information to the existing literature on the course of mental disorders in the community during the transition from adolescence to adulthood.

Anorexia nervosa trios: behavioral profiles of individuals with anorexia nervosa and their parents

BACKGROUND

Anorexia nervosa (AN) is associated with behavioral traits that predate the onset of AN and persist after recovery. We identified patterns of behavioral traits in AN trios (proband plus two biological parents).

METHOD

A total of 433 complete trios were collected in the Price Foundation Genetic Study of AN using standardized instruments for eating disorder (ED) symptoms, anxiety, perfectionism, and temperament. We used latent profile analysis and ANOVA to identify and validate patterns of behavioral traits.

RESULTS

We distinguished three classes with medium to large effect sizes by mothers' and probands' drive for thinness, body dissatisfaction, perfectionism, neuroticism, trait anxiety, and harm avoidance. Fathers did not differ significantly across classes. Classes were distinguished by degree of symptomatology rather than qualitative differences. Class 1 (approximately 33%) comprised low symptom probands and mothers with scores in the healthy range. Class 2 ( approximately 43%) included probands with marked elevations in drive for thinness, body dissatisfaction, neuroticism, trait anxiety, and harm avoidance and mothers with mild anxious/perfectionistic traits. Class 3 (approximately 24%) included probands and mothers with elevations on ED and anxious/perfectionistic traits. Mother-daughter symptom severity was related in classes 1 and 3 only. Trio profiles did not differ significantly by proband clinical status or subtype.

CONCLUSIONS

A key finding is the importance of mother and daughter traits in the identification of temperament and personality patterns in families affected by AN. Mother-daughter pairs with severe ED and anxious/perfectionistic traits may represent a more homogeneous and familial variant of AN that could be of value in genetic studies.

The Upper Bavarian longitudinal community study 1975-2004. 2. Long-term course and outcome of depression. A controlled study

OBJECTIVE

The study describes course and outcome over 25 years in depressed and non-depressed men and women from a large community study. Outcome measures covered psychopathology, disability, and impaired functioning.

METHOD

A depressive syndrome (depressed mood and three additional depressive symptoms) was defined and compared to a control condition without depressive symptoms in the seven days preceding baseline assessment. Assessments focused on three time points: baseline survey, 5-year follow-up, and 25-year follow-up. Self-rating scales as well as expert-rating interviews yielded data on a wide range of social and psychopathological risk factors and outcome measures.

RESULTS

Among participants of all three waves (N=838), the baseline prevalence for depressive syndrome was 18.1%. Depressive symptoms manifest at the first wave had substantial impact over the 25-year study. Subjects with a depressive syndrome were predisposed for later adverse mental health outcomes, more disability in social domains and reduced functionality. No long-term increase or decrease of the prevalence of the depressive syndrome was observed.

CONCLUSION

There is a persistent and long lasting impact of depressive syndrome, irrespective of diagnostic status, in the general population. Our results underscore the importance of sub-syndromal depressive syndrome when estimating the risk of future mental disorders and functional impairment in the long-term.

The Upper Bavarian longitudinal community study on psychopathology 1975-2004: 1. Methods and first results

OBJECTIVE

This paper presents background information on the methods and first results of the 25-years follow-up of the prospective longitudinal Upper Bavarian Study in the community. Longitudinal epidemiological studies which cover very long time spans require special methods. Issues concerning these requirements are discussed using design and experiences from the Upper Bavarian Study.

METHOD

Assessments focused on three time points: baseline survey, five-year follow-up, and 25-year follow-up. Self-rating scales as well as expert-rating interviews yielded data on a wide range of social and psychopathological risk factors and outcome measures.

RESULTS

Of the 1,342 study participants in the original sample, 390 had died during the 25-year follow-up period. Participation rate was 88% of those alive. At all three time points, a total of 838 participants were interviewed. Data on this unselected sample over a quarter century will be presented in forthcoming papers. Because of their mobility young individuals from our original sample were more difficult to follow up. We analyzed in detail data of subjects interviewed at t3 (and earlier time points) as compared to data from subjects not traced or reached, and subjects who refused to participate at wave t3. We found no evidence that the long-term outcome was biased by drop-out due to gender or earlier mental illness.

CONCLUSION

Methodological possibilities and limitations concerning long-term epidemiological studies across decades are presented and discussed.

Long-term course of binge eating disorder and bulimia nervosa: relevance for nosology and diagnostic criteria

OBJECTIVE

To present the twelve-year outcome of binge eating disorder (BED) in 68 female inpatients compared to bulimia nervosa, purging type (BN-P; N = 196).

METHOD

Self and expert ratings focused on the beginning of therapy and the 12-year follow-up.

RESULTS

36% of BED and 28.2% of BN-P patients still received an eating disorder diagnosis at follow-up. Differences between groups were small (Eating Disorder Inventory, Structured Inventory for Anorexic and Bulimic Syndromes, Hopkins Symptom Checklist, Beck Depression Inventory). Similar predictors for BED and BN-P were identified. Psychiatric comorbidity was the predominant predictor of poor outcome in both diagnoses. Predictors for BED outcome were body dissatisfaction, sexual abuse, and impulsivity; self-injury predicted BN-P outcome.

CONCLUSION

Course, outcome, and mortality were similar for BED and BN-P. Both disorders had psychiatric comorbidity as the main predictor of outcome, and there was a diagnostic shift between BED and BN-P over time, pointing to their nosological proximity. Data are relevant for the formulation of DSM-V and ICD-11 diagnostic criteria.

Influence of overanxious disorder of childhood on the expression of anorexia nervosa

OBJECTIVE

Childhood anxiety often precedes the onset of anorexia nervosa (AN) and may mark a liability to the emergence of an eating disorder for some women. This study investigates the prevalence of overanxious disorder (OAD) among women with AN and explores how OAD impacts AN symptoms and personality traits.

METHOD

Participants were 637 women with AN who completed an eating disorders history, the Structured Clinical Interview for DSM-IV Axis I Disorders, and assessments for childhood anxiety, eating disorder attitudes, and associated personality traits.

RESULTS

Of 249 women (39.1%) reporting a history of OAD, 235 (94.4%) met criteria for OAD before meeting criteria for AN. In comparison to those without OAD, women with AN and OAD self-reported more extreme personality traits and attitudes and they engaged in more compensatory behaviors.

CONCLUSION

Among individuals with AN, those entering AN on a pathway via OAD present with more severe eating disorder pathology.

The genetics of anorexia nervosa collaborative study: methods and sample description

OBJECTIVE

Supported by National Institute of Mental Health (NIMH), this 12-site international collaboration seeks to identify genetic variants that affect risk for anorexia nervosa (AN).

METHOD

Four hundred families will be ascertained with two or more individuals affected with AN. The assessment battery produces a rich set of phenotypes comprising eating disorder diagnoses and psychological and personality features known to be associated with vulnerability to eating disorders.

RESULTS

We report attributes of the first 200 families, comprising 200 probands and 232 affected relatives.

CONCLUSION

These results provide context for the genotyping of the first 200 families by the Center for Inherited Disease Research. We will analyze our first 200 families for linkage, complete recruitment of roughly 400 families, and then perform final linkage analyses on the complete cohort. DNA, genotypes, and phenotypes will form a national eating disorder repository maintained by NIMH and available to qualified investigators.

Temporal patterns of recovery across eating disorder subtypes

OBJECTIVE

To compare patterns of recovery in individuals with index episodes of anorexia nervosa (AN) and bulimia nervosa (BN).

METHOD

Using Kaplan-Meier methods and Cox proportional hazards models, comparisons were conducted that were conditional on duration of eating disorder from onset and included a conservative recovery criterion of 3 asymptomatic years. Data collection was retrospective and from two of the international Price Foundation genetic studies on 901 individuals with eating disorders.

RESULTS

Using Kaplan-Meier methods, 11% of those with index AN and 10% of those with index BN met recovery criteria at 10 years. At 15 years, 16% of those with index AN and 25% of those with index BN met recovery criteria. In a Cox proportional hazards model the index BN group had three times the rate of recovery at 10-14 years (p=0.01) than the index AN group.

CONCLUSIONS

Initially the probability of recovery was greater for those with index AN, but as the duration of the eating disorder lengthened those with BN had higher probabilities of recovery. Replication of these results with prospective data using similarly stringent recovery criteria and methods is required to confirm trends.

Impulse control disorders in women with eating disorders

We compared symptom patterns, severity of illness, and comorbidity in individuals with eating disorders with and without impulse control disorders (ICD), and documented the temporal pattern of illness onset. Lifetime ICD were present in 16.6% of 709 women with a history of eating disorders. The most common syndromes were compulsive buying disorder and kleptomania. ICD occurred more in individuals with binge eating subtypes, and were associated with significantly greater use of laxatives, diuretics, appetite suppressants and fasting, and with greater body image disturbance, higher harm avoidance, neuroticism, cognitive impulsivity, and lower self-directedness. In addition, individuals with ICD were more likely to have obsessive-compulsive disorder, any anxiety disorder, specific phobia, depression, cluster B personality disorder, avoidant personality disorder, and to use psychoactive substances. Among those with ICD, 62% reported the ICD predated the eating disorder and 45% reported the onset of both disorders within the same 3-year window. The presence of a lifetime ICD appears to be limited to eating disorders marked by binge eating and to be associated with worse eating-related psychopathology, more pathological personality traits, and more frequent comorbid Axis I and II conditions. Untreated ICD may complicate recovery from eating disorders.

Features associated with diet pill use in individuals with eating disorders

We investigated the relation between diet pill use and eating disorder subtype, purging and other compensatory behaviors, body mass index (BMI), tobacco and caffeine use, alcohol abuse or dependence, personality characteristics, and Axis I and Axis II disorders in 1,345 participants from the multisite Price Foundation Genetics Studies. Diet pill use was significantly less common in women with restricting type of AN than in women with other eating disorder subtypes. In addition, diet pill use was associated with the use of multiple weight control behaviors, higher BMI, higher novelty seeking, and the presence of anxiety disorders, alcohol abuse or dependence, and borderline personality disorder. Findings suggest that certain clinical and personality variables distinguish individuals with eating disorders who use diet pills from those who do not. In the eating disorder population, vigilant screening for diet pill use should be routine clinical practice.