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1.  Effects of Reducing the Frequency and Duration Criteria for Binge Eating on Lifetime Prevalence of Bulimia Nervosa and Binge Eating Disorder: Implications for DSM-5 
Objective
We assessed the impact of reducing the binge eating frequency and duration thresholds on the diagnostic criteria for bulimia nervosa (BN) and binge eating disorder (BED).
Method
We estimated the lifetime population prevalence of BN and BED in 13,295 female twins from the Swedish Twin study of Adults: Genes and Environment employing a range of frequency and duration thresholds. External validation (risk to co-twin) was used to investigate empirical evidence for an optimal binge eating frequency threshold.
Results
The lifetime prevalence estimates of BN and BED increased linearly as the frequency criterion decreased. As the required duration increased, the prevalence of BED decreased slightly. Discontinuity in co-twin risk was observed in BN between at least four times per month and at least five times per month. This model could not be fit for BED.
Discussion
The proposed changes to the DSM-5 binge eating frequency and duration criteria would allow for better detection of binge eating pathology without resulting in a markedly higher lifetime prevalence of BN or BED.
doi:10.1002/eat.20955
PMCID: PMC3235235  PMID: 21882218
3.  Anorexia Nervosa and Generalized Anxiety Disorder: Further Explorations of the Relation Between Anxiety and Body Mass Index 
Journal of anxiety disorders  2011;25(5):727-730.
We explore comorbidity of anorexia nervosa (AN) and generalized anxiety disorder (GAD) and their relation with body mass index (BMI) and evaluate the presence of fasting and excessive exercise which both have anxiolytic and weight loss effects. All participants were female: 32 with AN only, 607 with GAD only, 22 with AN and GAD (AN+GAD), and 5,424 with no history of AN or GAD (referent) from the Swedish Twin study of Adults: Genes and Environment (STAGE). Lowest adult BMI differed significantly (p < .001) and was lower in those with AN+GAD than those with AN only (p < .029). Those with AN+GAD were most likely to endorse fasting and excessive exercise, followed by women with AN only, women with GAD only, and the referent. Comorbid AN and GAD may be a particularly pernicious presentation influencing both BMI and proclivity to engage in behaviors such as fasting and exercise that serve both weight loss and anxiolytic goals.
doi:10.1016/j.janxdis.2011.03.010
PMCID: PMC3094688  PMID: 21514095
Anorexia nervosa; Generalized anxiety disorder; Body mass index; fasting; comorbidity
4.  Association of Candidate Genes with Phenotypic Traits Relevant to Anorexia Nervosa 
European Eating Disorders Review  2011;19(6):487-493.
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: (1) lowest illness-related attained body mass index; (2) age at menarche; (3) drive for thinness; (4) body dissatisfaction; (5) trait anxiety; (6) concern over mistakes; and (7) the anticipatory worry and pessimism vs. 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.
doi:10.1002/erv.1138
PMCID: PMC3261131  PMID: 21780254
covariates; eating disorders; association studies; personality; genetic
5.  Life Beyond the Eating Disorder: Education, Relationships, and Reproduction 
Objective
We investigated sociodemographic characteristics in women with and without lifetime eating disorders.
Method
Participants were from a multi-site international study of eating disorders (N = 2096). 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.
Conclusion
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 with educating patients and family members about long-term consequences of eating disorders.
doi:10.1002/eat.20804
PMCID: PMC2888627  PMID: 20143323
Children; relationship; education; anorexia nervosa; bulimia nervosa; amenorrhea
6.  Shared and Unique Genetic and Environmental Influences on Binge Eating and Night Eating: A Swedish Twin Study 
Eating behaviors  2009;11(2):92-98.
We applied twin methodology to female and male twin pairs to further understand the nature of the relation between two behaviors associated with eating disorders—binge eating (BE) and night eating (NE) in an effort to determine the extent of overlap of genetic and environmental factors influencing liability to these behaviors. We calculated heritability estimates for males and females for each behavior and applied bivariate twin modeling to the female data to estimate the genetic and environmental correlation between these two traits. Data on BE and NE were derived from the Swedish Twin Study of Adults: Genes and Environment (STAGE) of the Swedish Twin Registry (STR; N = 11604). Prevalence estimates revealed sex differences with females more likely to endorse BE and males more likely to endorse NE. In males, we were only able to estimate univariate heritabilities due to small sample sizes: The heritability for BE was .74 [95% CI = (0.36, 0.93)] and for NE was .44 [95% CI = (0.24, 0.61)]. The best fitting bivariate model for females included additive genetic and unique environmental factors as well as the genetic correlation between BE and NE. Heritability estimates were 0.70 [95% CI = (0.26, 0.77)] for BE and 0.35 [95% CI = (0.17, 0.52)] for NE. The genetic correlation, 0.66 [95% CI = (0.48, 0.96)] suggests considerable overlap in the genetic factors influencing liability to BE and NE. In females, there is considerable overlap in the genetic factors that contribute to these traits, but the incomplete overlap allows for the influence of independent genetic and environmental factors as well. BE and NE in females are therefore best conceptualized as related but not identical traits.
doi:10.1016/j.eatbeh.2009.10.004
PMCID: PMC2830904  PMID: 20188292
7.  Patterns of Comorbidity of Eating Disorders and Substance Use in Swedish Females 
Psychological medicine  2009;40(1):105-115.
Background
Little is known about the association of eating disorder (ED) subtypes across multiple categories of substance use (SU) in population-based samples. We examined the association between EDs and SU in a large population-based sample.
Method
Female participants (N=13,297) were from the Swedish Twin Registry (Lichtenstein et al., 2006). SU was examined in four defined groups − (1) anorexia nervosa (AN); (2) bulimia nervosa (BN); (3) anorexia nervosa and bulimia nervosa (ANBN); and (4) binge eating disorder (BED) as well as a referent group without EDs (no ED). Secondary analyses examined differences between restricting AN (RAN) and binge and/or purge AN (ANBP).
Results
In general, EDs were associated with greater SU 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 ED 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
EDs are associated with a range of SU behaviors. Improved understanding of how they mutually influence risk could enhance understanding of etiology and prevention.
doi:10.1017/S0033291709005662
PMCID: PMC2788663  PMID: 19379530
8.  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.
doi:10.1002/ajmg.b.31082
PMCID: PMC2963154  PMID: 20468064
single nucleotide polymorphisms; probands; anorexia nervosa; bulimia nervosa
9.  Understanding the Relation between Anorexia Nervosa and Bulimia Nervosa in a Swedish National Twin Sample 
Biological psychiatry  2010;67(1):71-77.
Background
We present a bivariate twin analysis of anorexia nervosa (AN) and bulimia nervosa (BN) 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 (STAGE) (N=7000), we calculated heritability estimates for narrow and broad AN and BN and estimated their genetic correlation.
Results
In the full model, the heritability estimate for narrow AN was (a2 = .57; 95% CI: .00, .81) and for narrow BN (a2 = .62; 95% CI: .08, .70) with the remaining variance accounted for by unique environmental factors. Shared environmental factors estimates were (c2 = .00; 95% CI: .00, .67) for AN and (c2 = .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 (a2 = .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.
doi:10.1016/j.biopsych.2009.08.010
PMCID: PMC2851013  PMID: 19828139

Results 1-9 (9)