T. Zucchi

Psychopathological and clinical features of outpatients with an eating disorder not otherwise specified

In order to investigate similarities and differences between Eating Disorder Not Otherwise Specified (EDNOS) and Anorexia Nervosa (AN) and Bulimia Nervosa (BN), we studied a consecutive series of 189 female outpatients attending two Eating Disorder Units. The data were collected by means of interviews (Eating Disorder Examination, EDE 12.0D), the Structured Diagnostic Interview for DSM III-R, (SCID), and self-reported questionnaires (Beck Depression Inventory, BDI, and State and Trait Anxiety Inventory, STAI 1–2). The diagnosis of EDNOS was as frequent as that of AN and BN (43.8% versus 43.2%). There were no significant differences between EDNOS and AN/BN patients in terms of their general and specific psychopathological features, but significant differences were observed between bulimic-like and anorectic-like EDNOS patìents, as well as between those with AN and BN. In conclusion, in our clinical setting, the patients with EDNOS and those with typical eating disorders have similar psychopathological features, thus suggesting that EDNOS patients should be further divided into two groups, anorectic-like (similar to AN) and bulimic-like (similar to BN) patients.

Screening for binge eating disorder in obese outpatients

The prevalence of binge eating disorder (BED) in clinical samples of obese patients is controversial, and sensitive diagnostic protocols for use in routine clinical practice need to be further defined. Three hundred forty-four obese (body mass index [BMI] > or =30 kg/m2) patients were studied with the Structured Clinical Interview for DSM-III-R to investigate the lifetime prevalence of mental disorders. The current prevalence of BED was assessed using DSM-IV criteria. Eating attitudes and behavior were investigated with the Bulimic Investigation Test, Edinburgh (BITE) and the Binge Eating Scale (BES). The Beck Depression Inventory (BDI) and Spielbergs State-Trait Anxiety Inventory (STAI) were also applied. The prevalence of BED was 7.5%. Patients with BED had a higher BMI compared with obese patients without BED. Differences in the lifetime prevalence of mental disorders in patients with and without BED were not statistically significant. Using the BES as a screening instrument for BED with a threshold of 17, the sensitivity was 84.8%, specificity 74.6%, positive predictive value 26.2%, and negative predictive value 97.9%. Using the BITE with a threshold of at least 10, the sensitivity was 91%, specificity 51.4%, positive predictive value 71.8%, and negative predictive value 98.2%. The BITE can be a valid alternative to the BES as a screening method for BED in obese patients.

Eating disorders and body image disturbances among ballet dancers, gymnasium users and body builders.

Background: Eating disorders are frequent among elite performers of certain sports or physical activities; however, little is known about non-professional performers. Method: 113 female non-elite ballet dancers, 54 female gymnasium users, 44 male non-competitive body builders, 105 female controls and 30 male controls were evaluated using the Body Uneasiness Test, the State-Trait Anxiety Inventory, the Beck Depression Inventory, and the Eating Disorder Examination 12th edition (EDE-12). Results: Non-elite ballet dancers reported the highest prevalence of eating disorders (anorexia nervosa 1.8%; bulimia nervosa 2.7%; eating disorders not otherwise specified 22.1%), followed by gymnasium users (anorexia nervosa 2.6%; eating disorders not otherwise specified 18%). Significant differences (p < 0.01) between athletes and their controls were found in the following parameters (median values): Beck Depression Inventory (female dancers 5.7, gymnasium users 6.1, female controls 2.8, body builders 1.6, and male controls 1.3), Body Uneasiness Test (female dancers 1.08, gymnasium users 0.62, female controls 0.54, body builders 0.35, and male controls 0.27), EDE total scores (female dancers 1.6, gymnasium users 1.7, female controls 1.0, body builders 1.0, and male controls 0.4), EDE – restraint subscale scores (female dancers 0.8, gymnasium users 1.6, female controls 0.0, body builders 0.8, and male controls 0.0), EDE – eating concern subscale scores (female dancers 0.4, gymnasium users 0.2, female controls 0.0, body builders 0.0, and male controls 0.0), EDE – weight concern subscale scores (female dancers 2.1, gymnasium users 2.1, female controls 1.6, body builders 1.4, and male controls 0.5), and EDE – shape concern subscale scores (female dancers 2.7, gymnasium users 2.8, female controls 2.0, body builders 2.1, and male controls 0.9). EDE scores were highly related to Body Uneasiness Test scores, especially in non-elite ballet dancers and in non-competitive body builders (p < 0.01). Conclusion: Non-professional performers of sports emphasising thinness or muscularity, such as ballet and body-building, show a high degree of body uneasiness and inappropriate eating attitudes and behaviours.

Eating behavior in obese patients with and without type 2 diabetes mellitus

Objective: Aim of this study was the assessment of the prevalence of eating disorders, and of eating disorder symptoms, in obese patients with type 2 diabetes, compared to non-diabetic subjects.Design: Three samples of individuals were studied: a series of 156 (76 male, 80 female) overweight and obese type 2 diabetic patients, aged 30–65 y, with a body mass index (BMI)>28 kg/m2 (DM); a series of 192 (20 male, 172 female) obese (BMI>30 kg/m2) non-diabetic patients aged 30–65 y seeking treatment for weight loss (OC); and a non-clinical sample of 48 (22 male, 26 female) obese (BMI>30 kg/m2) subjects aged 30–65 y selected from the lists of two general practices (OP). Eating behavior was assessed using the Eating Disorder Examination (EDE 12.0D).Results: The prevalence of Binge Eating Disorder was lower than 5% in all the three samples. Median EDE scores in females were significantly higher in OC (3.0) and OP (3.4) than in DM (1.7), while diabetic patients showed higher scores on Restraint than both non-diabetic samples. Among diabetic patients, a significant correlation of EDE scores with HbA1c was observed.Conclusions: Type 2 diabetes is unlikely to induce relevant eating disturbances in obese patients, apart from an increase in restraint. Abnormalities of eating attitudes and behavior are associated with an impairment of metabolic control.

Clinical Epidemiology of Eating Disorders: Results from the Sesto Fiorentino Study

Background: It is speculated that clinical samples do not fully reflect the characteristics of eating disorders (EDs) as they are in the general population, especially in their lowest range of severity. The present article reports the prevalence of EDs in a community sample aged >14 years, their clinical and psychopathological features, and their course and outcome on naturalistic grounds. Methods: The Sesto Fiorentino Study is a three-phase community-based survey where 2,355 out of 2,500 people representative of the population aged >14 years living in Sesto Fiorentino were evaluated by their own general practitioner using the Mini International Neuropsychiatric Interview plus six additional questions. All those who had positive results plus a probability sample of the non-cases were re-interviewed by psychiatrists using the Florence Psychiatric Interview. The subjects who reported ED symptoms were subsequently administered the Eating Disorder Examination (12th edition). Results: Overall, the lifetime prevalence of EDs was 1.21%. More precisely, 0.42% had anorexia nervosa, 0.32% bulimia nervosa, 0.32% binge eating disorder and 0.32% eating disorder not otherwise specified. All the subjects suffering from an ED fulfilled diagnostic criteria for at least another DSM-IV axis I psychiatric disorder. At the moment of the interview, conducted a few years (average 7 years) after the onset of the disorder, 50% had fully recovered from EDs, 26.9% were currently affected by an ED, 23.1% showed a persistent body image disturbance and/or the presence of compensatory behaviours. Conclusions: Community surveys conducted by clinicians may provide useful additional information on the psychopathological features, natural course and outcome of these disorders on naturalistic grounds.

Cognitive-Behavioural Therapy for Bulimia nervosa and Binge Eating Disorder

Cognitive-behavioural therapy (CBT) programmes for bulimia nervosa (BN) have been considerably refined during the last 2 decades, and such a treatment is now extensively used. The present paper describes the treatment rationale and structure, and reviews the available evidence on its efficacy. Compared to any other psychological or pharmacological treatment for which controlled studies have been published, CBT is reported to be more effective (the majority of studies), or at least as effective. A CBT programme for binge eating disorder (BED) has been created by adapting that of BN, but it has been less extensively evaluated in field trials. Even here, however, no other treatment has proven to be of greater efficacy than CBT. Various methodological limitations reduce the possibility of generalizing these findings. Moreover, CBT was found to be completely satisfactory neither for BN nor for BED, with moderate effectiveness and some limits. However, at the present state of treatment, no other therapeutical procedure seems to be more effective, more specific or more promising. It is speculated therefore that CBT could be presently considered the first-choice remedy for these severely disabling disorders.

The Eating Disorder Examination as a retrospective interview.

The purpose of this study was to determine the validity of the Eating Disorder Examination 12.0D (EDE) when administered retrospectively. Methods. Twenty-five female patients suffering from an eating disorder [(10 with anorexia nervosa (AN), 10 with bulimia nervosa (BN), 5 with eating disorders not otherwise specified (EDNOS)] were investigated using the EDE at the time of the first referral to our outpatient ward (T1). Afterwards (mean 1.4±0.6 years later) each patient was administered again the EDE by the same assessor (T2). At this time the interviewer asked the patients to answer the questions referring to the symptoms and behaviours at the time of the first interview. Results. Test-retest correlation factors were 0.7 or greater for all subscales of the EDE (p<0.0001) and 0.5 or greater for every single item of the EDE (p<0.001), except for EDE 1.5 (snack after dinner) and EDE 9A.6 (maximum time free from objective bulimic episodes in the last two months). Discussion. Our results provide evidence that the EDE 12.0D is a reliable interview even when administered retrospectively, suggesting the use of this instrument for the retrospective assessment of eating disorders.

Eating attitudes and behavior throughout the menstrual cycle in obese women: A case-control study

Premenstrual variations of eating behavior are reported in several studies, but their relationship with mood is unclear. Eating behavior and physical and psychological complaints during the menstrual cycle were studied in 107 obese patients and 93 matched controls using retrospective (Weekly Bulimic Test Edinburgh, W-BITE and Premenstrual Assessment Form, PAF) and prospective (Daily Rating Form, DR) questionnaires. Eating disorder symptoms increased in the premenstrual phase, as shown by the W-BITE scores both in patients (6.2±5.3 premenstrual week vs 4.9±4.4 postmenstrual week, p< 0.05) and in control subjects (4.9±4.1 premenstrual week vs 4.2±3.0 postmenstrual week, p<0.05) and were correlated to premenstrual complaints in control subjects (r=0.5; p<0.05) but not in obese women (r=0.2; p=NS). A close relationship between physical and psychological premenstrual disturbances was observed in obese patients only. Premenstrual variation of eating behavior could be the target of specific treatment.