Emily M. Pisetsky

Disordered eating and substance use in high-school students: results from the Youth Risk Behavior Surveillance System.

OBJECTIVE To examine the association between disordered eating (fasting, diet product use, and vomiting or laxative use) and use of 10 substances (cigarettes, alcohol, marijuana, cocaine, inhalants, heroin, methamphetamines, ecstasy, steroids, and hallucinogens) in a nationally representative adolescent sample. METHOD Participants were 13,917 U.S. high-school students participating in the 2005 Youth Risk Behavior Surveillance System. RESULTS Disordered eating was significantly associated with the use of each substance. Using effect size estimates that take base rates into consideration, for female students, associations between substance use and disordered eating were weak for all but three forms of substance use: current smoking, binge drinking, and inhalants. Among male students, strong (marijuana, steroids, and inhalants) or moderate effects (all other substances) were observed. CONCLUSION Future research needs to focus on inhalant use and methamphetamine use in males. Increased medical attention should be directed toward adolescents who practice disordered eating behaviors because they are also at elevated risk for using cigarettes, alcohol, inhalants, methamphetamines, and steroids.

Mobile therapy: use of text-messaging in the treatment of bulimia nervosa.

OBJECTIVE To examine a text-messaging program for self-monitoring symptoms of bulimia nervosa (BN) within the context of cognitive-behavioral therapy (CBT). METHOD Thirty-one women participated in 12 weekly group CBT sessions and a 12 week follow-up. Participants submitted a text message nightly indicating the number of binge eating and purging episodes and rating their urges to binge and purge. Automatic feedback messages were tailored to their self-reported symptoms. RESULTS Fully 87% of participants adhered to self-monitoring and reported good acceptability. The number of binge eating and purging episodes as well as symptoms of depression (BDI), eating disorder (EDI), and night eating (NES) decreased significantly from baseline to both post-treatment and follow-up. DISCUSSION Given the frequent use of mobile phones and text-messaging globally, this proof-of-principle study suggests their use may enhance self-monitoring and treatment for BN leading to improved attendance, adherence, engagement in treatment, and remission from the disorder.

Understanding the relation between anorexia nervosa and bulimia nervosa in a Swedish national twin sample.

BACKGROUND We present a bivariate twin analysis of anorexia nervosa and bulimia nervosa to determine the extent to which shared genetic and environmental factors contribute to liability to these disorders. METHOD Focusing on females from the Swedish Twin study of Adults: Genes and Environment (n = 7000), we calculated heritability estimates for narrow and broad anorexia nervosa and bulimia nervosa and estimated their genetic correlation. RESULTS In the full model, the heritability estimate for narrow anorexia nervosa (AN) was (a(2) = .57; 95% confidence interval [CI]: .00-.81) and for narrow bulimia nervosa (BN) (a(2) = .62; 95% CI: .08-.70), with the remaining variance accounted for by unique environmental factors. Shared environmental factors estimates were (c(2) = .00; 95% CI: .00-.67) for AN and (c(2) = .00; 95% CI: .00-.40) for BN. Moderate additive genetic (.46) and unique environmental (.42) correlations between AN and BN were observed. Heritability estimates for broad AN were lower (a(2) = .29; 95% CI: .04-.43) than for narrow AN, but estimates for broad BN were similar to narrow BN. The genetic correlation for broad AN and BN was .79, and the unique environmental correlation was .44. CONCLUSIONS We highlight the contribution of additive genetic factors to both narrow and broad AN and BN and demonstrate a moderate overlap of both genetic and unique environmental factors that influence the two conditions. Common concurrent and sequential comorbidity of AN and BN can in part be accounted for by shared genetic and environmental influences on liability although independent factors also operative.

Patterns of co-morbidity of eating disorders and substance use in Swedish females

BACKGROUND Little is known about the association of eating disorder subtypes across multiple categories of substance use in population-based samples. We examined the association between eating disorders and substance use in a large population-based sample. METHOD Female participants (n=13 297) were from the Swedish Twin Registry [Lichtenstein et al., Twin Research and Human Genetics (2006) 9, 875-882]. Substance use was examined in four defined groups - (1) anorexia nervosa (AN); (2) bulimia nervosa (BN); (3) AN and BN (ANBN); and (4) binge eating disorder (BED) as well as a referent group without eating disorder (no ED). Secondary analyses examined differences between restricting AN (RAN) and binge and/or purge AN (ANBP). RESULTS In general, eating disorders were associated with greater substance use relative to the referent. The AN group had significantly increased odds for all illicit drugs. Significant differences emerged across the RAN and ANBP groups for alcohol abuse/dependence, diet pills, stimulants, and polysubstance use with greater use in the ANBP group. Across eating disorder groups, (1) the BN and ANBN groups were more likely to report alcohol abuse/dependence relative to the AN group, (2) the ANBN group was more likely to report diet pill use relative to the AN, BN and BED groups, and (3) the BN group was more likely to report diet pill use relative to the no ED, AN and BED groups. CONCLUSIONS Eating disorders are associated with a range of substance use behaviors. Improved understanding of how they mutually influence risk could enhance understanding of etiology and prevention.

Uniting Couples (in the treatment of) Anorexia Nervosa (UCAN).

OBJECTIVE To describe the development of a novel couple-based cognitive-behavioral intervention for adult anorexia nervosa (AN) called Uniting Couples (in the treatment of) Anorexia Nervosa (UCAN). METHOD We review the state of the science for the treatment of adult AN, the nature of relationships in AN, our model of couple functioning in AN, and the development of the UCAN intervention. RESULTS We present the UCAN treatment for patients with AN and their partners and discuss important considerations in the delivery of the intervention. DISCUSSION With further evaluation, we expect that UCAN will emerge to be an effective, acceptable, disseminable, and developmentally tailored intervention that will serve to improve both core AN pathology as well as couple functioning.

Suicide attempts in women with eating disorders.

We evaluated whether the prevalence of lifetime suicide attempts/completions was higher in women with a lifetime history of an eating disorder than in women with no eating disorder and assessed whether eating disorder features, comorbid psychopathology, and personality characteristics were associated with suicide attempts in women with anorexia nervosa, restricting subtype (ANR), anorexia nervosa, binge-purge subtype (ANBP), lifetime history of both anorexia nervosa and bulimia nervosa (ANBN), bulimia nervosa (BN), binge eating disorder (BED), and purging disorder (PD). Participants were part of the Swedish Twin study of Adults: Genes and Environment (N = 13,035) cohort. Lifetime suicide attempts were identified using diagnoses from the Swedish National Patient and Cause of Death Registers. General linear models were applied to evaluate whether eating disorder category (ANR, ANBP, ANBN, BN, BED, PD, or no eating disorder [no ED]) was associated with suicide attempts and to identify factors associated with suicide attempts. Relative to women with no ED, lifetime suicide attempts were significantly more common in women with all types of eating disorder. None of the eating disorder features or personality variables was significantly associated with suicide attempts. In the ANBP and ANBN groups, the prevalence of comorbid psychiatric conditions was higher in individuals with than without a lifetime suicide attempt. The odds of suicide were highest in presentations that included purging behavior (ANBN, ANBN, BN, and PD), but were elevated in all eating disorders. To improve outcomes and decrease mortality, it is critical to be vigilant for suicide and identify indices for those who are at greatest risk.

Eating Disorders and Problematic Eating Behaviours Before and After Bariatric Surgery: Characterization, Assessment and Association with Treatment Outcomes

Abstract Accumulating evidence suggests that bariatric surgery candidates are likely to present with eating disorders (EDs) and/or problematic eating behaviours (EBs), and research suggests that these problems may persist or develop after bariatric surgery. While there is growing evidence indicating that EDs and EBs may impact bariatric surgery outcomes, the definitions and assessment methods used lack consensus, and findings have been mixed. The aims of this paper were (1) to summarize the existing literature on pre‐operative and post‐operative EDs and problematic EBs; (2) to discuss the terms, definitions and assessment measures used across studies; and (3) to consider the extent to which the presence of these problems impact surgery outcomes. We highlight the importance of investigators utilizing consistent definitions and assessment methodologies across studies.

Eating Disorders and Problematic Eating Behaviours Before and After Bariatric Surgery

Abstract Accumulating evidence suggests that bariatric surgery candidates are likely to present with eating disorders (EDs) and/or problematic eating behaviours (EBs), and research suggests that these problems may persist or develop after bariatric surgery. While there is growing evidence indicating that EDs and EBs may impact bariatric surgery outcomes, the definitions and assessment methods used lack consensus, and findings have been mixed. The aims of this paper were (1) to summarize the existing literature on pre‐operative and post‐operative EDs and problematic EBs; (2) to discuss the terms, definitions and assessment measures used across studies; and (3) to consider the extent to which the presence of these problems impact surgery outcomes. We highlight the importance of investigators utilizing consistent definitions and assessment methodologies across studies.

Self-image and suicide in a Swedish national eating disorders clinical register

OBJECTIVE Using a prospective design, to examine the relation between self-image (assessed using the Structural Analysis of Social Behavior) and suicide attempts/completions in women with anorexia nervosa-restricting type (ANR), anorexia nervosa-binge/purge type (ANBP), bulimia nervosa (BN), binge eating disorder (BED), and eating disorder not otherwise specified (EDNOS); and to assess whether these self-image variables add unique predictive value to suicide when considering other baseline predictors. METHOD Women (N=2269) aged 12 to 45 (M=22.1) presenting to specialist eating disorders clinics in Sweden between 2005 and 2009 were identified through the Stepwise Eating Disorders Quality Register. Data on age, body mass index, eating disorder severity (Eating Disorder Examination-Questionnaire scores), psychiatric comorbidity, global assessment of functioning, and self-image were abstracted from Stepwise and included as baseline predictors or covariates. Suicide information (prior attempt and attempt/completion after Stepwise registration) was obtained from the National Patient Register and Cause of Death Register. RESULTS Prevalence of detected suicide attempts/completions over the study period was 9.2%. Negative self-image variables were associated with prior suicide attempts in ANR and EDNOS and later suicide attempts/completions in women with BN. In a stepwise Cox proportional hazards model, only low self-affirmation predicted time to suicide attempts/completions in women with BN when accounting for age and prior suicide attempt. CONCLUSION Assessing self-image might assist with identifying women with BN at elevated risk for suicide.

Exploratory study to decrease postprandial anxiety: Just relax!

OBJECTIVE Critical first steps in the treatment of anorexia nervosa (AN) include re-nutrition and weight restoration, both highly anxiety provoking for patients. We explored the impact of progressive muscle relaxation (PMR), guided imagery (GI), self-directed relaxation (SR), and control (C) on reducing postprandial anxiety in 64 females with AN. METHOD Participants began the study upon hospital admission. They received relaxation training after lunch for 15 days. Pre- and post-session anxiety and treatment acceptability ratings were made daily. RESULTS Although all conditions improved relaxation and decreased anxiety, feelings of fullness, and thoughts about weight, the three active conditions significantly reduced anxiety and increased relaxation more than C (p < .0001). Participants significantly enjoyed the three active treatments, were more likely to recommend them to a friend, and were more likely to use either PMR or GI again versus C (p < .0001). CONCLUSION Relaxation may be a valuable component for reducing postprandial anxiety in AN.