Kelly A. Gendall

Serotonin neuronal function and selective serotonin reuptake inhibitor treatment in anorexia and bulimia nervosa

Anorexia nervosa (AN) and bulimia nervosa (BN) are disorders characterized by aberrant patterns of feeding behavior and weight regulation, and disturbances in attitudes toward weight and shape and the perception of body shape. Emerging data support the possibility that substantial biologic and genetic vulnerabilities contribute to the pathogenesis of AN and BN. Multiple neuroendocrine and neurotransmitter abnormalities have been documented in AN and BN, but for the most part, these disturbances are state-related and tend to normalize after symptom remission and weight restoration; however, elevated concentrations of 5-hydroxyindoleacetic acid in the cerebrospinal fluid after recovery suggest that altered serotonin activity in AN and BN is a trait-related characteristic. Elevated serotonin activity is consistent with behaviors found after recovery from AN and BN, such as obsessionality with symmetry and exactness, harm avoidance, perfectionism, and behavioral over control. In BN, serotonergic modulating antidepressant medications suppress symptoms independently of their antidepressant effects. Selective serotonin reuptake inhibitors (SSRIs) are not useful when AN subjects are malnourished and under-weight; however, when given after weight restoration, fluoxetine may significantly reduce the extremely high rate of relapse normally seen in AN. Nonresponse to SSRI medication in ill AN subjects could be a consequence of an inadequate supply of nutrients, which are essential to normal serotonin synthesis and function. These data raise the possibility that a disturbance of serotonin activity may create a vulnerability for the expression of a cluster of symptoms that are common to both AN and BN and that nutritional factors may affect SSRI response in depression, obsessive-compulsive disorder, or other conditions characterized by disturbances in serotonergic pathways.

Leptin, neuropeptide Y, and peptide YY in long-term recovered eating disorder patients

BACKGROUND Disturbances of leptin, neuropeptide Y (NPY), and peptide YY (PYY) have been found in women who are ill with anorexia or bulimia nervosa. It is not certain whether peptide disturbances are cause or consequence of eating disorders. METHODS Plasma leptin and cerebrospinal fluid leptin, NPY, and PYY concentrations were measured in women who were recovered from anorexia or bulimia nervosa to determine whether alterations persisted after recovery. RESULTS NPY, PYY, and leptin concentrations were similar across all diagnostic groups. CONCLUSIONS Alterations in NPY, PYY, and serum leptin concentrations are probably secondary to pathological eating behaviors. Alterations of these peptides are unlikely to be trait-related disturbances that contribute to the etiology of eating disorders.

Personality and dimensions of dietary restraint

OBJECTIVE Given that dietary restraint and associated dietary behavior may predispose individuals to frank eating disorders, and that differences in personality profiles have been observed across subtypes of eating disorders, we sought to address whether aspects of restrained eating (cognitive restraint, disinhibition, and susceptibility to hunger) could be distinguished using the Temperament and Character Inventory (TCI). METHOD One hundred and one women aged 18-45 selected at random from the community completed the Diagnostic Interview for Genetic Studies (DIGS), the TCI, and the Three Factor Eating Questionnaire (TFEQ). RESULTS Novelty seeking (NS) was significantly positively correlated with disinhibition. Self-directedness (SD) was negatively correlated with the total TFEQ score, disinhibition, and susceptibility to hunger. Self-transcendence (ST) correlated positively with total TFEQ score and cognitive restraint. DISCUSSION These findings suggest that individuals with character traits denoting low SD and high ST may be particularly reactive and susceptible to societal messages pertaining to the ideology of slenderness.

Effects of acute tryptophan depletion on mood in bulimia nervosa

BACKGROUND The present study investigated the role of serotonin in the pathophysiology of bulimia nervosa (BN) by studying the affective and appetitive responses of women ill with BN to an acute tryptophan depletion (ATD) paradigm. METHODS Twenty-two women with BN and 16 healthy control women (CW) were studied on 2 separate days during the follicular stage of the menstrual cycle. Participants drank a control mix of essential amino acids (100 g + 4.6 g tryptophan) on one day and a tryptophan deficient (100 g - 4.6 g tryptophan) mixture (ATD) on the other in a double-blind fashion. Mood/appetite ratings and blood samples were taken at baseline and at intervals up to 420 minutes. Participants were then presented with an array of foods and were allowed to binge and vomit if they desired. RESULTS CW and BN women had a similar and significant reduction in plasma tryptophan levels and the tryptophan: LNAA ratio after ATD. After ATD, the BN women had a significantly greater increase in peak (minus baseline) depression, mood lability, sadness and desire to binge compared to the CW. BN subjects and CW had similar peak changes in mood after the control amino acid mixture. BN subjects and CW consumed similar amounts of food after the two amino acid treatments. CONCLUSIONS Women with BN seem more vulnerable to the mood lowering effects of ATD, suggesting they have altered modulation of central 5-HT neuronal systems.

The nutrient intake of women with bulimia nervosa

OBJECTIVE The objective of this study was to evaluate the meal patterns and nutrient intake of women with bulimia nervosa (BN), and to compare them to clinical variables and recommended dietary allowances (RDA). METHOD The nutrient intake of 50 women with BN was analyzed from 14 day dietary records. The data were compared to the median intakes of a random sample of women and to the RDA. Clinical variables for the women with BN were also available. RESULTS Compared to nonbinge episodes per day, binge eating was significantly higher in energy from sucrose, fat, saturated fatty acids (SFA), monounsaturated fatty acids (MUFA) and lower in protein. Compared to the population median, binge eating was significantly lower in percent energy from protein, and higher in percent carbohydrate (CHO), sucrose, SFA, and MUFA, while nonbinge eating was significantly lower in percent energy from fat, SFA, and MUFA. Total intakes were significantly higher in energy and percent energy sucrose compared to the population. Despite significantly lower nonbinge energy intake, calcium, vitamins A and C, iron, and folate were not significantly different to the population median. However, one half or more of the subjects had less than two-thirds the RDA for nonbinge calcium, iron, zinc and for total intake one fourth remained less than two-thirds the RDA for iron and zinc. CONCLUSION Nonbinge eating was characterized by low energy intake and by low intake of iron, calcium, and zinc. Binge eating, characterized by high sucrose and SFA content, overcompensated for these low energy intakes. Where treatment reduces or eliminates binge eating, it should also encourage consumption of regular meals and in particular, consumption of foods rich in zinc and iron.

The significance of a prior history of anorexia in bulimia nervosa

OBJECTIVE Some authors stratify women with current, normal-weight bulimia nervosa into groups defined by the presence or absence of a past history of anorexia nervosa. Unlike the distinction between current anorexia nervosa with or without bulimic symptoms, fewer studies have investigated the significance of stratifying bulimic women by a past history of anorexia. METHOD One hundred and fourteen women with bulimia nervosa in a clinical trial were studied via structured clinical interviews covering Axis I and II disorders and measures of personality and symptomatology. Prospective, 14-day dietary analysis was available for a subset of subjects. RESULTS Bulimic women with a past history of anorexia nervosa were significantly more likely to have a lifetime anxiety disorder, lower current body mass index, increased cooperativeness on the Temperament and Character Inventory, and increased mature and neurotic scores on the Defense Style Questionnaire. These women also reported lower scores on the bulimia subscale of the Eating Disorders Inventory, but these self-report data were not consistent with the numbers of objective binges or reported energy intake. The prevalence of other Axis I disorders, Axis II personality disorders, and bulimic symptomatology was quite similar across groups. CONCLUSIONS Although bulimic women with a prior history of anorexia nervosa differed in limited respects from those without such a history, the differences were outweighed by the similarities. A past history of anorexia nervosa did not appear to define particularly meaningful subgroups of women with current, normal-weight bulimia nervosa.

Psychopathology and personality of young women who experience food cravings

The objective of the present study was to investigate the psychopathology and personality characteristics of women who experience food cravings. A total of 101 young women selected at random from the community completed the Diagnostic Interview for Genetic Studies with a trained interviewer. The interview included a section about food-craving experiences and associated factors. Subjects also completed a self-report questionnaire booklet containing the Temperament and Character Inventory (TCI) and the Eating Disorder Inventory (EDI). Compared to noncravers, women who reported food cravings were significantly more likely to report a history of alcohol abuse/dependence (p = .003), significant weight changes (p = .003), and to have undertaken dieting (p = .02), bingeing (p = .05), vomiting (p = .02), exercise (p = .04), diet pill (p = .03), and laxative use (p = .01) to control weight. There was a trend for the cravers to have higher novelty-seeking scores on the TCI (p = .06). Our findings suggest that women who experience food cravings are more likely to have met criteria for alcohol abuse/dependence and tend to have temperament characterized by higher levels of novelty seeking. In addition the high rates of eating-disorder symptomatology implies overconcern with body weight and shape in the women who experienced food cravings.

New directions in treatment research of anorexia and bulimia nervosa

Although considerable progress has been made in the understanding and treatment of anorexia and bulimia nervosa, a substantial proportion of people with these disorders have a limited response to treatment. Treatment strategies used in eating disorders have tended to be adopted from therapies that were devised to treat other psychiatric illnesses. Recent studies suggest that eating disorders are independently transmitted familial liabilities with a unique pathophysiology. These new findings raise the possibility that an improved understanding of the pathogenesis of eating disorders will generate more specific and effective psychotherapies and pharmacologic interventions.

Menstrual cycle irregularity in bulimia nervosa Associated factors and changes with treatment

OBJECTIVES This study determined the clinical and nutritional variables associated with menstrual disturbance in women with bulimia nervosa (BN). METHODS Eighty-two women with DSM-IV BN underwent psychiatric, nutritional and menstrual related assessments prior to an outpatient treatment programme and at 12 months follow-up. RESULTS Forty-five percent reported a current irregular menstrual cycle. A high frequency of vomiting, low thyroxine concentrations and low dietary fat intake were independently associated with irregular menses at pretreatment. At 12 months follow-up, 30.5% reported irregular menstrual cycles. A greater difference between past maximum and minimum body weight, smoking and depression were associated with menstrual irregularity at 12 months follow-up. Of those with irregular menstrual cycles at pretreatment, 56.8% became regular at 12 months follow-up. CONCLUSION Menstrual irregularity in BN is associated with indices of nutritional restriction that are not reflected by low body weight or energy intake. Depression, cigarette smoking and fluctuations in body weight may act as metabolic stresses that contribute to the perpetuation of menstrual disturbances.

Food cravings in women with a history of anorexia nervosa.

OBJECTIVE The objective of the present study was to determine the prevalence and characteristics of food cravings in women with a history of anorexia nervosa. METHOD One hundred one control women selected at random and 64 women with a diagnosis of anorexia nervosa 10 to 14 years earlier (cases) completed the Diagnostic Interview for Genetic Studies, a food craving questionnaire, the Temperament and Character Inventory and the Three-Factor Eating Questionnaire. RESULTS A similar proportion of cases and controls reported food cravings. A greater proportion of cases reported strong cravings with two or more features of intensity (p = .02). Cravings in the cases were more likely to be characterized by difficulty resisting the craved food (p = .0008), anxiety when the craved food was unavailable (p = .002), and a high frequency of occurrence (p = .001). The cases who craved were significantly more likely to have had lifetime BN (p = .02). CONCLUSION A similar prevalence of food craving in cases as in controls suggests that successful control of food intake and/or denial of hunger overrides dietary restriction as a precondition for craving in anorexia nervosa. A dysfunction in the serotonergic system, the provision of intermittent reinforcement by binge episodes, and/or frustration due to unsuccessful attempts at dietary restraint may mediate the association of cravings with the presence of lifetime bulimia.