Tiffany A. Brown

Update on course and outcome in eating disorders

OBJECTIVE To review recent studies describing eating disorder course and outcome. METHOD Electronic and manual searches were conducted to identify relevant articles published since 2004. RESULTS Twenty-six articles were identified. For anorexia nervosa (AN), most patients ascertained through outpatient settings achieved remission by 5-year follow-up. Inpatient treatment predicted poor prognosis as inpatient samples demonstrated lower remission rates. Outcome differed between bulimia nervosa (BN) and eating disorders not otherwise specified (EDNOS), including binge eating disorder (BED), for shorter follow-up durations; however, outcomes appeared similar between BN and related EDNOS by 5-year follow-up. Greater psychiatric comorbidity emerged as a significant predictor of poor prognosis in BN, whereas few prognostic indicators were identified for BED or other EDNOS. DISCUSSION Results support optimism for most patients with eating disorders. However, more effective treatments are needed for adult AN inpatients and approximately 30% of patients with BN and related EDNOS who remain ill 10-20 years following presentation.

Comparison of DSM-IV versus proposed DSM-5 diagnostic criteria for eating disorders: reduction of eating disorder not otherwise specified and validity.

OBJECTIVE Revised Eating Disorder (ED) diagnostic criteria have been proposed for the Diagnostic and Statistical Manual (DSM)-5 to reduce the preponderance of eating disorder not otherwise specified (EDNOS) and increase the validity of diagnostic groups. This article compares DSM-IV and proposed DSM-5 diagnostic criteria on number of EDNOS cases and validity. METHOD Participants (N = 397; 91% female) completed structured clinical interviews in a two-stage epidemiological study of EDs. Interviewers did not follow standard skip rules, making it possible to evaluate alternative ED diagnostic criteria. RESULTS Using DSM-IV versus DSM-5 criteria, 34 (14%) versus 48 (20%) had anorexia nervosa, 43 (18%) versus 44 (18%) had bulimia nervosa, and 163 (68%) had EDNOS versus 20 (8%) had binge eating disorder (BED), and 128 (53%) had EDNOS, respectively, reflecting a significant decrease in EDNOS. Validation analyses supported significant differences among groups with some improvement associated with delineation of BED. DISCUSSION Proposed revisions to EDs in the DSM-5 significantly reduced reliance on EDNOS without loss of information.

The enigma of male eating disorders: A critical review and synthesis

Historically, male presentations of eating disorders (EDs) have been perceived as rare and atypical - a perception that has resulted in the systematic underrepresentation of males in ED research. This underrepresentation has profoundly impacted clinical practice with male patients, in which i) stigmatization and treatment non-engagement are more likely, ii) a distinct array of medical complexities are faced, and iii) symptom presentations differ markedly from female presentations. Further, the marginalization of males from ED research has hindered the assessment and clinical management of these presentations. This critical review provides an overview of the history of male EDs and synthesizes current evidence relating to the unique characteristics of male presentations across the diagnostic spectrum of disordered eating. Further, the emerging body of evidence relating to muscularity-oriented eating is synthesized in relation to the existing nosological framework of EDs. The impact of marginalizing male ED patients is discussed, in light of findings from epidemiological studies suggesting that clinicians will be increasingly likely to see males with ED in their practices. It is suggested that changes to current conceptualizations of ED pathology that better accommodation male ED presentations are needed.

Retrospective analysis of the tolerability and activity of lacosamide in patients with brain tumors: clinical article.

OBJECT The object of this study was to determine the tolerability and activity of lacosamide in patients with brain tumors. METHODS The authors reviewed the medical records at 5 US academic medical centers with tertiary brain tumor programs, seeking all patients in whom a primary brain tumor had been diagnosed and who were taking lacosamide. RESULTS The authors identified 70 patients with primary brain tumors and reviewed seizure frequency and toxicities. The majority of the patients had gliomas (96%). Fifty-five (78%) had partial seizures only, and 12 (17%) had generalized seizures. Most of the patients (74%) were started on lacosamide because of recurrent seizures. Forty-six patients (66%) reported a decrease in seizure frequency, and 21 patients (30%) reported stable seizures. Most of the patients (54 [77%]) placed on lacosamide did not report any toxicities. CONCLUSIONS This retrospective analysis demonstrated that lacosamide was both well tolerated and active as an add-on antiepileptic drug (AED) in patients with brain tumors. Lacosamides novel mechanism of action will allow for concurrent use with other AEDs, as documented by its activity across many different types of AEDs used in this patient population. Larger prospective studies are warranted.

Current and Emerging Directions in the Treatment of Eating Disorders

Eating disorders are a significant source of psychiatric morbidity in young women and demonstrate high comorbidity with mood, anxiety, and substance use disorders. Thus, clinicians may encounter eating disorders in the context of treating other conditions. This review summarizes the efficacy of current and emerging treatments for anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). Treatment trials were identified using electronic and manual searches and by reviewing abstracts from conference proceedings. Family based therapy has demonstrated superiority for adolescents with AN but no treatment has established superiority for adults. For BN, both 60 mg fluoxetine and cognitive behavioral therapy (CBT) have well-established efficacy. For BED, selective serotonin reuptake inhibitors, CBT, and interpersonal psychotherapy have demonstrated efficacy. Emerging directions for AN include investigation of the antipsychotic olanzapine and several novel psychosocial treatments. Future directions for BN and BED include increasing CBT disseminability, targeting affect regulation, and individualized stepped-care approaches.

The impact of relationships on the association between sexual orientation and disordered eating in men

OBJECTIVE Robust evidence supports that bisexual and gay (BG) men have increased eating pathology compared to heterosexual men. BG men may be at greater risk due to pressure to attract a male partner; however, the related implication that relationships serve as protective factors for BG men remains untested. METHOD BG (n = 42) and heterosexual men (n = 536) completed surveys to determine whether relationship status and satisfaction moderate sexual orientations effect on disordered eating. RESULTS Single BG men had increased restrictive disordered eating compared to single heterosexual men, while few differences were found between BG and heterosexual men in relationships. Relationship satisfaction was not related to restrictive disordered eating; however, low relationship satisfaction was associated with increased bulimic symptomatology in BG men compared to heterosexual men. DISCUSSION Being in a relationship, independent of whether or not the relationship is satisfying, may be a protective factor for restrictive disordered eating in BG men.

Defining features of unhealthy exercise associated with disordered eating and eating disorder diagnoses

OBJECTIVES The current study sought to compare different features of unhealthy exercise on associations with disordered eating and their ability to identify individuals with eating disorders. A secondary aim of the study was to compare prevalence and overlap of different aspects of unhealthy exercise and potential differences in their gender distribution. DESIGN Cross-sectional epidemiological study. METHODS A community-based sample of men (n=592) and women (n=1468) completed surveys of health and eating patterns, including questions regarding exercise habits and eating disorder symptoms. RESULTS Compulsive and compensatory features of exercise were the best predictors of disordered eating and eating disorder diagnoses compared to exercise that was excessive in quantity. Further, compulsive and compensatory aspects of unhealthy exercise represented overlapping, yet distinct qualities in both men and women. CONCLUSIONS Including the compulsive quality among the defining features of unhealthy exercise may improve identification of eating disorders, particularly in men. Results suggest that the compensatory aspect of unhealthy exercise is not adequately captured by the compulsive aspect of unhealthy exercise. Thus, interventions that target unhealthy exercise behaviors among high-risk individuals, such as athletes, may benefit from addressing both the compulsive and compensatory aspects of unhealthy exercise. Future prospective longitudinal studies will aid in determining the direction of the association between these features of unhealthy exercise and the onset of eating pathology.

What are we missing? The costs versus benefits of skip rule designs

Many research diagnostic interviews employ skip rules, such that some questions are only asked based on answers to prior questions. In the context of large‐scale epidemiological studies, skip rules are important to study feasibility by reducing the time, money, and participant burden required for assessment. However, less is understood about information lost when questions are skipped. This study examines the relative prevalence, clinical significance, and additional time required to assess eating disorder symptom patterns skipped in the Structured Clinical Interview for DSM‐IV Axis I Disorders (SCID‐I) to understand the costs and benefits of following skip rules. Data come from the second stage of a two‐stage cohort sample (N = 400) in which the SCID‐I eating disorders module was administered without following skip rules. Results were weighted to correct for the sampling framework. Over a third of subjects endorsed symptoms that would have been missed had skip rules been followed. Uncaptured symptom patterns were associated with increased psychosocial impairment, and the additional time required to assess all symptoms averaged 1.8 minutes per participant. Clinically significant symptom patterns are missed by the SCID‐I and similar diagnostic tools, suggesting that epidemiologic studies using such instruments under‐estimate the prevalence and public health impact of mental disorders. Copyright

Personality pathology in purging disorder and bulimia nervosa

OBJECTIVE To compare levels of personality pathology in women with purging disorder (PD), bulimia nervosa (BN), and controls and to compare women with PD and BN on associations between personality pathology and shared eating disorder features. METHOD Women with BN (n = 73), PD (n = 48), and controls (n = 64) completed interviews and self-report questionnaires. RESULTS BN and PD were associated with significantly greater personality pathology compared to controls. Cluster C symptoms and trait anxiety were greater in BN compared to PD, but groups did not differ on Cluster B symptoms or impulsivity. Subjective binge episodes were associated with anxious and impulsive personality traits in PD but not BN. Purging in PD was associated with trait anxiety, while purging in BN was associated with impulsivity. DISCUSSION Although BN and PD share eating disorder features and personality disturbance, some of the underlying associations between these eating disorder and personality features differ between groups.

Weight suppression predicts bulimic symptoms at 20-year follow-up: The mediating role of drive for thinness.

Weight suppression predicts the onset and maintenance of bulimic syndromes. Despite this finding, no study has examined psychological mechanisms contributing to these associations using a longitudinal design. Given societal pressures to be thin and an actual history of higher weight, it is possible that greater weight suppression contributes to increased fear of gaining weight and preoccupation with being thin, which increase vulnerability to eating disorders. The present study investigated whether greater drive for thinness mediates associations between weight suppression and bulimic symptoms over long-term follow-up. Participants were women (n = 1,190) and men (n = 509) who completed self-report surveys in college and 10- and 20-years later. Higher weight suppression at baseline predicted higher bulimic symptoms at 20-year follow-up (p < .001), while accounting for demographic variables and baseline bulimic symptoms, body mass index, and drive for thinness. Increased drive for thinness at 10-year follow-up mediated this effect. Findings highlight the long-lasting effect of weight suppression on bulimic symptoms and suggest that preoccupation with thinness may help maintain this association. Future studies would benefit from incorporating other hypothesized consequences of weight suppression, including biological factors, into risk models.