[ "Weight phobia". A discussion of the problem of "atypical" and "not otherwise specified" eating and weight disorders]

A number of authors have stated that the problem of classifying patients whose diagnosis does not meet all the criteria of anorexia and bulimia nervosa has not been satisfactorily solved. The question has been asked if it is justified to regard characteristics like "weight phobia" or body image disturbance as valid diagnostic criteria. In the present study the differences observed in three groups of patients with eating and weight disorders (anorexia: n = 42; bulimia: n = 29; atypical group without "weight phobia": n = 14) were compared using the Giessen-Test. The atypical group was shown to be significantly more "tractable" on scale 2 than the main groups, which achieved a higher score on "dominance". Significant differences between the atypical group and the "uncontrolled" group of patients with bulimia were noted for scale 3, with the atypical group showing comparable results to those recorded in the anorexic group on "compulsiveness". The authors discuss the significance of the results under an epistemological aspect. The description and classification of clinical phenomena which is based on the clinical manifestation of the disorder independently of theoretical concepts is therefore indispensible for realising a uniform basis for communication by researchers worldwide. Equally indispensible is the differentiation or "extension" of the classification to allow a more detailed systematic categorisation guided along specific theoretical concepts. This requires the operational definition of psychopathological and psychodynamic criteria as, e.g. "the struggle for identy" or the "relentless pursuit of thinness". The experiences with the OPD (Operationalized Psychodynamic Diagnosis; 1996) have shown this to be a difficult but viable approach.

Theatres of the psyche

Fragments of the analytic voyage of a forty year old patient, haunted by the idea of her death since infancy when confronted with the anguish that accompanies the discovery of a potentially death dealing illness. In three years of intensive analytic work, her way of functioning psychically changed dramatically (her flight from imaginative life, total disaffectation of her emotional life, psychic deafness regarding her body and its messages...). These discoveries led to my analysand's resuming her psychoanalytic voyage in these words: 'Even if I am destined to die of this cancer, at least I shall have lived'.

Using the eating disorder examination in the assessment of bulimia and anorexia: issues of reliability and validity

OBJECTIVE

The Eating Disorder Examination will be assessed according to its reliability and validity in the assessment of anorexia nervosa and bulimia nervosa.

METHOD

A thorough review of the literature was conducted to judge the reliability and validity of the Eating Disorder Examination and its subscales.

RESULTS

The review shows that the EDE and its subscales have good interrater reliability and internal consistency reliability. Similarly, high levels of discriminant validity, construct validity, and treatment validity in the assessment of eating disorders were also found. A summary of each study concerning the various types of reliability and validity will be provided.

CONCLUSIONS

The EDE is considered to be the "gold standard" by which to identify eating disorders, so this tool used in conjunction with other behavioral measures will be imperative for clinical social work practice.

Differential feeding patterns induced by tumor growth and by TPN

The effects of anorexia induced by early tumor, and anorexia induced by total parenteral nutrition (TPN) on food intake and the indexes of food intake, were investigated in rats infused with saline after jugular catheter placement and concomitant inoculation with methylcholanthrene (MCA)-induced tumor cells on day 0, and in rats without catheters receiving tumor only. Tumor became palpable around day 10 and increased to represent 6-8% of host body weight by day 26. On day 18, food intake started to decrease. Catheter-bearing rats were then randomized to saline controls (n = 9) for 11 d or to TPN-100 (n = 9) for 4 d providing 100% of daily caloric needs. Both then received saline until day 26. Food intake and feeding indexes were continuously measured using the Automated Computerized Rat Eater Meter (ACREM) and data was analyzed using ANOVA and regression analysis. In controls (both with and without catheter) the tumor induced a specific feeding pattern which consisted of a significant (P < 0.01) decrease in food intake via a significant (P < 0.05) decrease in meal size. A non-significant decrease in meal number and meal duration occurred. Two other feeding-related activities, meal consumption rate and intermeal sniffs, also decreased. Infusion of TPN-100 into the already anorectic rat led to a further significant (P < 0.0001) decrease in food intake via a significant decrease in both meal size (P < 0.0001) and in meal number (P < 0.0001). A decrease in all other feeding indexes also occurred, resulting in a different feeding pattern. After stopping TPN-100, the TPN-100-induced feeding pattern returned to that of the tumor-induced feeding pattern. That the tumor-induced feeding pattern differs from the TPN-100-induced feeding pattern suggests that the mechanisms whereby these two factors induce anorexia may also differ.

Eating patterns in women with multiple sclerosis

For persons with multiple sclerosis (MS), good nutrition has the potential to enhance quality of life and reduce the risk of lifestyle diseases and secondary conditions. The purpose of this study was to describe nutritional intake of women with MS and to determine what factors influenced their intake. Based on 3-day food diary data, participants had an inadequate intake (< 10% lower than recommended) of carbohydrates, dietary fiber, vitamin E, calcium and zinc. In contrast, they consumed saturated fat, protein, vitamin A, vitamin C, folate and iron at higher levels than recommended. Age was significantly related to nutritional intake with older women consuming fewer calories, total fat and saturated fat. Despite evidence supporting the importance of following recommended nutritional guidelines, nutritional intake for participants in this study was not optimum in many important areas. This study supports the need for interventions to promote good nutrition among persons with MS.

Psychological factors in nutritional disorders of the elderly: part of the spectrum of eating disorders

OBJECTIVE

To illustrate common psychogenic factors involved in undereating and undernutrition in the elderly.

METHOD

Two cases are described.

RESULTS

In the context of age-related physical and social factors, obsessional, phobic, and hypochondriacal anxieties can lead to significant food restrictions and undernutrition.

DISCUSSION

Psychogenic factors need to be considered in undernutrition of the elderly and the phenomena considered in the spectrum of eating disorders.

Diet-induced enhancement of naloxone sensitivity is independent of changes in body weight

Intake of palatable solutions can enhance the anorectic potency of opioid antagonists. This experiment examined the relative contributions of orosensory experience and body weight gain to the enhanced anorectic potency of naloxone (0.125, 0.25, 0.5, and 1.0 mg/kg i.p.). Four groups of male hooded Lister rats (Charles River) were maintained on separate feeding regimes for 3 months. S-ADLIB rats were nondeprived with free access to lab chow and 20% (w/v) sucrose solution. S-RESTRICT rats received limited sucrose (50 ml/day) and chow (15 g/day) access, yoking their body weights to ADLIB rats receiving free access to lab chow only. RESTRICT rats received approx. 15 g of chow/day to maintain their body weights at 90% of the ADLIB rats. Fifteen-minute sucrose intake tests revealed marked differences between naloxone sensitivity of chronic sucrose drinkers and sucrose-naive groups. Intakes of S-ADLIB and S-RESTRICT were suppressed at all doses (max suppression >60%). In comparison to animals given sucrose, ADLIB and RESTRICT animals were significantly less sensitive (maximum suppression = 35%). Naloxone potency was independent of body weight differences. The data demonstrate that overconsumption of palatable ingesta, and not diet-induced weight gain, is sufficient to enhance antagonist potency. The study confirms that orosensory stimulation can induce plasticity in opioid systems, supporting an important role for opioids in intake regulation and general reward processes.

TCDD-induced anorexia and wasting syndrome in rats: effects of diet-induced obesity and nutrition

Interactions of diet and diet-induced obesity, and the characteristic wasting syndrome caused by 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) were studied in TCDD-resistant Han/Wistar and TCDD-sensitive Long-Evans rats. The rats were made obese by feeding them either a high-energy diet (consisting of chocolate, cheese, and chow) or force feeding. TCDD reduced body weight in a parallel manner in lean and obese rats. The high-energy diet diminished the body weight loss and increased the survival time in L-E rats after a lethal dose of TCDD, while energy supplement with high-fat/low-protein food had an opposite effect. In conclusion, diet-induced obesity and TCDD had additive effects on body weight. Dietary manipulations were able to modify the weight loss and survival time after TCDD. Fat seems to have a negative impact, while carbohydrate or protein may have a positive impact in this respect. The results are in agreement with a view that TCDD-exposed rats have a negative fat balance favoring fat loss.

[A multicenter study of expenditure and success in psychodynamic therapy of eating disorders. Study design and initial results]

Evaluation of psychodynamically oriented treatment of anorectic and bulimic patients, taking into account both quality and cost of therapist ("How much therapy is applied to which patients for a successful treatment?"). Criteria for indication of the kind of therapy and of amount of therapy ("dosage") are provided.

METHOD

Prospective naturalistic longitudinal study (comparable to phase IV of effectiveness studies on pharmaceuticals) including 2.5 year follow-up. Consecutive sample (Anorexia nervosa and bulimia nervosa, DSM-III-R). Multidimensional outcome measures including self-rating and expert-ratings. Operationalisation of outcome is layered. Differentiated measurement of amount of therapy and treatment elements. Survival analysis, logistic regression.

RESULTS

1171 completely documented treatment episodes of 43 institutions (30.3% Anorexia nervosa, 55.3% bulimia nervosa, 14.4% double diagnoses). Patients are chronically ill (M = 7.6 years; SD = 6.3 years) and at the beginning of (mostly inpatient) treatment of the index episode 25.5 years of age (SD = 6.0 years). Therapies last appr. 11 weeks (median) and encompass a broad range of therapy measures.

DISCUSSION

Study conduction as well as data collection and analysis of this worldwide largest study on treatment of eating disorders is discussed by presenting preliminary results.

CCK(A) and 5-HT3 receptors interact in anorectic responses to amino acid deficiency

Serotonin3 (5-HT3) receptors in the periphery mediate anorectic responses to the amino acid deficiency, which occurs after eating amino acid-imbalanced diets (IMB). However, other neurochemical systems, notably cholecystokinin (CCK), are known to affect food intake. We pretreated rats systemically with tropisetron, a 5-HT3 receptor antagonist, alone and combined with antagonists of CCK(A) and CCK(B) receptors, and measured intake of an IMB. Devazepide, a CCK(A) receptor antagonist, appeared to interact with tropisetron in the anorectic responses to IMB, blunting the usual remediation of IMB anorexia by tropisetron. The CCK(B) receptor antagonist, L-365, 260, increased intake of both IMB and an amino acid-balanced basal diet (BAS) and did not interact with tropisetron. Our data suggest that activation of CCK(A) receptors is interactive with 5-HT3 receptor activity in mediating IMB anorexia in the aminoprivic feeding model.

Frames of reference utilized in the rehabilitation of individuals with eating disorders

An occupational therapist's role with clients diagnosed with eating disorders, both anorexia nervosa and bulimia nervosa, has been described throughout the literature. However, the frames of reference and treatment approaches that occupational therapists implement have not been clearly established or validated. This paper outlines the symptomatology of anorexia nervosa and bulimia nervosa, and critically reviews the current literature concerning the frames of reference and treatment approaches used by occupational therapists when intervening with this population. The literature reviewed indicates that therapists are using a variety of frames of reference and treatment approaches. There appears to be an emphasis on the psychoanalytical and cognitive-behavioural frames of reference, although there is a lack of empirical evidence in regards to all frames of reference and treatment approaches. Reasons for the lack of current research with this population, and possible future areas of research are suggested.

[A case of anorexia at an early age]

We report a case of early-age anorexia for which no organic etiology has been found so far. This case raises many unsolved questions. Early-age anorexia is rarely described in medical literature. No nosographical consensus has been established. In front of these children who refused eating, it is important to confronted with consider the psychological and somatical aspects to prevent later effects on the cognitive development.

Structured Interview for Anorexic and Bulimic disorders for DSM-IV and ICD-10: updated (third) revision

OBJECTIVES

Earlier versions of the Structured Interview for Anorexic and Bulimic Disorders (SIAB) were modified in order to include new research findings and to update the expert rating interview to the diagnostic criteria of DSM-IV and ICD-10. The semistandardized interview was developed for reliable and valid assessment of the specific as well as the general psychopathology of eating disorders.

METHOD

Data from SIAB-EX interviews (current and past/lifetime symptom expression) were available from three samples: (a) 330 eating-disordered patients assessed at the start of treatment, (b) 148 former eating-disordered patients with anorexia nervosa (AN) or bulimia nervosa (BN) assessed at follow-up, and (c) 111 community controls. Sixty-one of the 87 items of the SIAB-EX with a 5-point scale were factor analyzed.

RESULTS

Principal components analyses with varimax rotation produced the following six components of the SIAB-EX (lifetime): (I) Body Image and Slimness Ideal; (II) General Psychopathology; (III) Sexuality and Social Integration; (IV) Bulimic Symptoms; (V) Measures to Counteract Weight Gain, Fasting, and Substance Abuse; and (VI) Atypical Binges. The factor solution for the current symptom expression was very similar to that based on lifetime symptom expression. Average item and factor scores are given for six groups of eating-disordered patients and controls. High interrater reliability was established for both current and the past symptom expression. Cronbach's alpha coefficients indicated good internal consistency for five of the six components of the SIAB-EX. DSM-IV and ICD-10 diagnoses for eating disorders can be derived directly or by using a computer algorithm from the SIAB-EX. A detailed 90-page manual facilitates the training of interviewers.

CONCLUSION

The 87-item SIAB-EX was originally developed for detailed assessment of eating disorders cross-sectionally and longitudinally. The updated version which allows for diagnosis according to DSM-IV and ICD-10 is described here.

Cytokine-induced anorexia. Behavioral, cellular, and molecular mechanisms

Cytokines induce anorexia. Recent issues concerning mechanistic aspects are: (1) Cytokines induce anorexia through different modes of behavioral action, that is, by affecting meal size, meal duration, and meal frequency differentially. Profiles also depend on the concentration or dosage. (2) The interface between the periphery and brain. Specific cytokines may be transported from the periphery to the brain. Cytokines generate mediators that can act on peripheral and/or brain target sites. Cerebrovasculature endothelium can also generate signals to modulate neural activities. Evidence indicates that the proposed vagal afferent signaling requires reassessment. Because of paracrine and autocrine actions, local cytokine production within the brain can induce anorexia. (3) Cytokines act directly on hypothalamic neurons proposed to participate in feeding. (4) Cytokine<-->cytokine and cytokine<-->peptide/neurotransmitter interactions are critical; for example, cytokines interact to induce anorexia synergistically, neuropeptide Y<-->cytokine interactions are antagonist, and cytokine<-->neurotransmitter and cytokine<-->leptin<-->neuropeptide Y<-->CRH-glucocorticoid and other endocrine interactions are important. A leptin receptor is related to gp 130, a signal transducer among interleukin (IL)-6 subfamily receptors; gp 130 and related molecules may be an interface for feeding control in health and disease. Various cytokines upregulate leptin and gp 130. An integrative approach combining computerized meal pattern analyses with cellular and molecular approaches is being used to characterize mechanisms (ligands, receptors, transducing molecules, and intracellular mediators) involved in cytokine-induced anorexia.

Feeding the anorectic client: comfort foods and happy hour

The anorectic patient presents a dilemma to the health care provider. As the patient refuses oral intake, quality of life diminishes, and health care costs increase. This article describes two approaches that have demonstrated effectiveness: comfort food and happy hour. "Comfort foods" describe foods associated with bygone years, intended to trigger recollections of pleasant childhood experiences and feelings of caring and healing. A second alternative described is the offering of a "happy hour" beverage, presented in a social milieu. These treatments are reproducible in a variety of clinical care settings and stimulate oral intake in the failure-to-thrive patient.

Lipopolysaccharide-induced anorexia following hepatic portal vein and vena cava administration

To examine the role of the liver in lipopolysaccharide (LPS)-induced hypophagia, we investigated the effect of hepatic portal and vena cava infusions (1 mL/30 min) of LPS (100 microg/kg of body weight) on feeding in rats. LPS infusion significantly reduced food intake when administered via either the hepatic portal vein or the vena cava. Both the magnitude and time course of this hypophagia were similar regardless of the infusion route. As in previous experiments of ours in which LPS was administered by intraperitoneal (i.p.) injection, LPS reduced food intake by decreasing meal frequency, without affecting meal size or duration. The results suggest that peripherally administered LPS does not act primarily in the liver to reduce food intake.

Treatment of compulsive behaviour in eating disorders with intermittent ketamine infusions

We have previously shown that eating disorders are a compulsive behaviour disease, characterized by frequent recall of anorexic thoughts. Evidence suggests that memory is a neocortical neuronal network, excitation of which involves the hippocampus, with recall occurring by re-excitement of the same specific network. Excitement of the hippocampus by glutamate-NMDA receptors, leading to long-term potentiation (LTP), can be blocked by ketamine. Continuous block of LTP prevents new memory formation but does not affect previous memories. Opioid antagonists prevent loss of consciousness with ketamine but do not prevent the block of LTP. We used infusions of 20 mg per hour ketamine for 10 h with 20 mg twice daily nalmefene as opioid antagonist to treat 15 patients with a long history of eating disorder, all of whom were chronic and resistant to several other forms of treatment. Nine (responders) showed prolonged remission when treated with two to nine ketamine infusions at intervals of 5 days to 3 weeks. Clinical response was associated with a significant decrease in Compulsion score: before ketamine, mean +/- SE was 44.0 +/- 2.5; after ketamine, 27.0 +/- 3.5 (t test, p = 0.0016). In six patients (non-responders) the score was: before ketamine, 42.8 +/- 3.7; after ketamine, 44.8 +/- 3.1. There was no significant response to at least five ketamine treatments, perhaps because the compulsive drive was re-established too soon after the infusion, or because the dose of opioid antagonist, nalmefene, was too low.

The postnatal emergence of dehydration anorexia in rats is temporally associated with the emergence of dehydration-induced inhibition of gastric emptying

Osmotic dehydration produced by systemic hypertonic NaCl (HS) inhibits gastric motility and emptying and also inhibits feeding in adult rats. Conversely, in neonatal rats, dehydration does not inhibit feeding. The present study examined whether the postnatal emergence of dehydration anorexia is temporally associated with the emergence of dehydration-induced inhibition of gastric emptying. Rat pups 4 to 19 days old were injected subcutaneously with HS (0.75 M NaCl; 200 microL/10 g body weight). Control rats were injected with isotonic saline (0.15 M NaCl). Thirty minutes later, rats were given access to milk that could be lapped from paper towels on the floor of a warm testing chamber. Other HS-treated and control rats were given an intragastric load of 0.15 M NaCl (2% body weight) and then killed after 30 min to determine how much of the load had emptied from the stomach. Consistent with previous reports, HS-treated rats consumed significantly more milk than control rats from postnatal Day 4 (P4) through P11 but consumed significantly less milk than controls at P19. HS treatment did not affect gastric emptying of 0.15 M NaCl at P4 or P11. Conversely, HS treatment significantly inhibited gastric emptying at P19. These findings suggest that the hypophagic effects of dehydration develop in tandem with inhibitory effects on gastric motility and are consistent with the view that the full complement of mature homeostatic responses to plasma hyperosmolality requires coordinated activation of forebrain and hindbrain neural circuits that are only partially formed in neonatal rats.

Relationship of body energy status to inflammation-induced anorexia and weight loss

The response to acute inflammation of rats at two levels of prior weight reduction were compared with normal-weight rats to examine how prior alterations in body energy status influence inflammation-induced anorexia and weight loss. Specifically, body weights were either reduced by 6%, the level of weight loss expected in normal-weight rats following induction of acute inflammation, or by 12%, a level 6% below that expected of the normal-weight rats. Rats were either allowed to eat ad lib. on postinflammation Day 1 or were kept on food restriction until Day 5, when anorexia was no longer expected to be present. As predicted, normal-weight rats allowed to eat ad lib. beginning Day 1 displayed the most severe anorexia. Total food intake of this group over the first 5 days following inflammation induction was 33% less than the control (CON) group. Rats with 6% prior weight reduction displayed a milder anorexia, eating only 15% less than the CON group over the first 5 days. In contrast, rats with 12% prior weight reduction ate the same amount of food as the CON group. Interestingly, similar feeding patterns were observed in rats that resumed ad lib. feeding on Day 5. The outcome of these various feeding patterns was to bring body weights of all the inflammation groups to the same level, approximately 6% below CON group weights. These results provide further evidence that proinflammatory mediators induce a temporary reduction in the amount of body tissue (weight) spontaneously maintained that is directly proportionate to the magnitude of insult.

Perceptions of bed rest by anorexic patients

OBJECTIVE

Few studies have investigated perceptions of operant conditioning programs by anorexic patients. This study examined patients' perceptions of the Bed Rest (BR) component which is employed in some operant conditioning programs.

METHODS

A sample of 48 anorexic inpatients was administered a survey to elicit their attitudes towards BR.

RESULTS

Results from the survey suggested that most patients perceived BR in a negative way. The main complaint, however, was not punishment or humiliation, as predicted, but isolation and boredom. A number of patients concluded that they wanted more individualization and distraction and less restriction while on BR.

DISCUSSION

The findings justify the use of BR within a humane framework in the inpatient treatment of anorexia nervosa, but suggest that patients' perceptions of BR warrant systematic scrutiny.

Reflections on prevention in dieting-induced disorders

OBJECTIVE

The purpose of this article is to reflect on current approaches to the prevention of anorexia nervosa and bulimia nervosa.

METHOD

The literature on preventing those disorders was examined within the context of the published literatures concerned with preventive interventions for adolescent drug-taking and alcohol-related behaviors.

RESULTS

Our review revealed that those involved in preventing eating disorders maintain the traditional distinction between primary and secondary prevention, although the fruitfulness of that categorization is now uncertain.

DISCUSSION

It is argued that interventions for dieting-induced disorders ought to be generic, and target the gamut of transitional risk behaviors among adolescents. Programs for dieting, cigarette smoking, alcohol use, and safe sex within the health and social development curricula in schools must be sustained by comprehensive efforts within the broader context of societal and systemic change.

Attentional biases in eating disorders: a visual probe detection procedure

OBJECTIVE

To investigate attentional biases for body shape and weight-related stimulus words among subjects with anorexia nervosa, bulimia nervosa, and control subjects classified using a measure of dietary restraint.

METHODS

A visual probe detection task was used to assess attention toward stimulus words reflecting either a thin or a large physique and positively or negatively valenced emotion words.

RESULTS

In comparison to controls, subjects with eating disorders detected target probes more slowly when they appeared in the same location as had stimulus words connoting a thin physique. In addition, there was a trend toward faster detection or target probes that appeared in the same location as had stimulus words connoting a large physique. Neither of these effects were observed among restrained eaters.

DISCUSSION

Our results extend prior work suggesting information-processing biases for body shape and weight-related stimuli among persons with eating disorders.

Cross-cultural validity of the Eating Disorder Inventory: a study of Chinese patients with eating disorders in Hong Kong

OBJECTIVE

To evaluate the cross-cultural validity of the Chinese version of the Eating Disorder Inventory (EDI) in a clinical sample of patients with eating disorders in Hong Kong.

METHOD

After comprehensive clinical assessment, a consecutive series (1990-1996) of Chinese patients with bulimia nervosa (N = 17) and broadly diagnosed anorexia nervosa (N = 26) completed the Chinese EDI. Results were compared with those of Chinese female undergraduates (N = 606) and Canadian patients with eating disorders.

RESULTS

The EDI profiles of bulimic and fat phobic anorectic patients were remarkably and modestly similar to those of their Canadian counterparts. The EDI meaningfully distinguished bulimic patients and fat phobic anorectic patients from local undergraduates, but exhibited deficient criterion-related validity in nonfat phobic anorectic patients.

DISCUSSION

The questionable validity of certain EDI subscales in nonfat phobic patients reflects the ethnospecific constructs upon which they are based, and weakens the efficacy of the EDI in screening for anorexia nervosa in Chinese populations. Apart from illustrating some of the conceptual and methodological issues that need to be tackled in the cross-cultural study of the eating disorders, this study furnishes empirical support for the syndromal homogeneity of bulimia nervosa, and the clinical grouping of anorexia nervosa into fat phobic and nonfat phobic subtypes.

Social physique anxiety and disordered eating: what's the connection?

Social physique anxiety (SPA) is highly correlated with other body image measures that have been considered to be important in understanding eating disorders. However, SPA has not been directly studied with respect to eating disorders. Thus, the purpose of this investigation was to examine the link between SPA and measures of eating disorder symptomatology to determine if SPA should be considered as an additional risk factor in the prediction of eating disturbances. One hundred and sixty female undergraduates completed questionnaires measuring body mass index (BMI), social physique anxiety (SPAS), anorexic symptoms (EAT), bulimic symptoms (BULIT-R), depression (CES-D), self-esteem (SES) and obligatory exercise (OEQ). Regression analyses revealed that SPA and depression were the psychological correlates that predicted bulimic symptomatology and that SPA, depression, and obligatory exercise predicted anorexic symptomatology; all variables were positively related to eating disorder symptoms. Overall, the results indicate that social physique anxiety appears to be a useful construct for understanding eating disorder symptoms in female undergraduates.

Reflections on some dynamics of eating disorders: 'no entry' defences and foreign bodies

In the context of the treatment of eating disorders, the author describes a specific failure in the container/contained relationship (Bion, 1962) that goes beyond the experience of having projections rejected. She addresses the predicament of those patients who have not only lacked containment, but also perceived themselves as receptacles of unmetabolised phantasies and experiences projected into them by their parents. The author briefly refers to those patients who succeed in protecting themselves from this predicament by developing a 'no entry system of defences' that often includes anorexia. The main focus of the clinical exploration in this paper is the predicament of 'porous' patients, those who remain open to parental projections. The author suggests that in such cases the introjection of an object performing a function opposite to organising 'alpha function' can be hypothesised. She suggests the term 'omega function' to describe a disorganising, disrupting agent in the patient's internal world. The author makes reference to the type of countertransference experienced by the clinician working with the disorganised 'porous' patients, which is different from the type experienced in the treatment of patients prone to envious attacks and, in particular, to attacks on linking.

Anorexia of aging: physiologic and pathologic

Despite the increase in body fat and obesity that occurs with aging, there is a linear decrease in food intake over the life span. This conundrum is explained by decreased physical activity and altered metabolism with aging. Thus, older persons fail to adequately regulate food intake and develop a physiologic anorexia of aging. This physiologic anorexia depends not only on decreased hedonic qualities of feeding with aging (an area that remains controversial) but also on altered hormonal and neurotransmitter regulation of food intake. Findings in older animals and humans have provided clues to the causes of the anorexia of aging. An increase in circulating concentrations of the satiating hormone, cholecystokinin, occurs with aging in humans. In addition, animal studies suggest a decrease in the opioid (dynorphin) feeding drive and possibly in neuropeptide Y and nitric oxide. The physiologic anorexia of aging puts older persons at high risk for developing protein-energy malnutrition when they develop either psychologic or physical disease processes. Despite its high prevalence, however, protein-energy malnutrition in older persons is rarely recognized and even more rarely treated appropriately. Screening tools for the early detection of protein-energy malnutrition in older persons have been developed. Multiple treatable causes of pathologic anorexia have been identified. There is increasing awareness of the importance of depression as a cause of severe weight loss in older persons. Approaches to the management of anorexia and weight loss in older persons are reviewed. Although many drugs exist that can enhance appetite, none of these are ideal for use in older persons currently.

Do individuals at risk for eating disorders exhibit negative priming deficits?

Fifty people (25 at risk for an eating disorder, 25 controls) performed a simple reaction-time (SRT) task and a negative-priming (NP) task. The two groups did not differ on the SRT task. For the NP task, the controls displayed the NP effect (responses on critical trials were slower than responses on control trials). At-risk participants, however, revealed no such NP effect. Although the pattern of NP performance in the at-risk participants may indicate that they as a group had deficiencies in their ability to inhibit irrelevant information, it is also possible that issues related to obsessionality, perfectionism, and restraint in the at-risk group affected the results.

Selective processing of shape-related words in women with eating disorders, and those who have recovered

OBJECTIVES

This study sought to investigate whether women with anorexia or bulimia nervosa and women who had recovered showed cognitive bias towards shape, food and adolescent issues.

DESIGN

A five-group analysis of variance design was used, in which the different client groups were the independent variables. The dependent variable was performance on an emotional Stroop task.

METHODS

Current anorexia sufferers (N = 31), current bulimia sufferers (N = 24), recovered anorexics (N = 23), recovered bulimics (N = 11) and women who had never suffered from eating disorders (N = 33) were recruited through health-care professionals, support groups and newspapers. Colour-naming times for target and comparison Stroop cards were measured.

RESULTS

Women currently suffering from bulimia, and women who had recovered from anorexia, were found to be more distracted by shape concerns than women who had never suffered eating disorders and women who had recovered from bulimia.

CONCLUSIONS

The results suggest that there may be an enduring cognitive bias among women who have recovered from anorexia. This is the first study in which impairment on an emotional Stroop task has been found to persist after recovery from a clinical condition.

The night eating syndrome in the general population and among postoperative obesity surgery patients

OBJECTIVE

To determine the prevalence of night-eating syndrome in the general population and among a new sample of obesity surgery patients.

METHODS

Night-eating syndrome was defined by presence of morning anorexia, excessive evening eating, evening tension and/or feeling upset, and insomnia. A randomly selected sample of 2,097 adults (survey sample) answered structured interview questions on night-eating syndrome. A self-report form was completed by 111 patients who had received gastric restriction surgery for obesity at a patient reunion (patient sample).

RESULTS

Prevalence of night-eating syndrome in the survey sample was 1.5% (31 of 2,097). Prevalence in the patient sample was 27% (30 of 111). Weights for subjects in each sample, with and without the syndrome, were comparable.

DISCUSSION

Prevalence of night-eating syndrome was higher in the patient sample than in the survey sample. Within each sample, presence of the syndrome was not related to weight. Prevalence in the survey sample was within the range reported for binge-eating disorder. Night-eating syndrome may warrant consideration as a distinct eating disorder.

Disordered eating patterns, body image, self-esteem, and physical activity in preadolescent school children

OBJECTIVE

Eating disorders have been typically defined as an "adolescent problem." As a result of emerging evidence which indicated this health problem to be evident in the prepubescent age range, this study aimed to establish prevalence and factors associated with eating/dieting, physical activity, and body image among a nonclinical, naturalistically-derived sample of preadolescent (aged 10 and 11) school children (n = 61).

METHOD

This cohort of children, which represented the entire grade 6 class of a suburban Elementary school, was measured for body image satisfaction [silhouettes], a participation in activity index, a self-worth scale and a measure of eating attitudes & behavior [Eating and Me scale [E & M]].

RESULTS

The longitudinal assessment of body image [3 measures over 9 months] indicated signs of stability of "actual" assessments of body image for males, but marked changes for females who preferred to be ideally "chunkier" in stature over time. Physical activity was only implicated with bulimia for the male sub-group. The E & M scale reported a Cronbach's alpha of .76, with two factors [bulimia; drive for thinness/anorexia] representing 65% of the total variance. Moderate internal validity [r .58] between body dissatisfaction on the E & M scale and the silhouette measure was observed.

DISCUSSION

These results demonstrated that body image views and concerns appeared before puberty, that gender differences prevailed with respect to eating/dieting, activity and body image, and that the E & M scale has emerged as a promising research tool. The longitudinal nature of this study of eating disorders also promotes the need for qualitative research methodology and attention to pre-pubertal cognitive/perceptual processes.

Relationships between alexithymia and psychological characteristics associated with eating disorders

This study examines the relationships between alexithymia and psychological characteristics and behaviors that are commonly associated with eating disorders. The 20-item Toronto Alexithymia Scale (TAS-20) and the Eating Disorder Inventory (EDI) were administered to a group of 48 female patients with anorexia nervosa, a matched comparison group of 30 normal women, and an unmatched comparison group of 116 male and 118 female university students. In the anorexic and male student groups, the TAS-20 correlated significantly and positively with the EDI subscales, Ineffectiveness, Interpersonal Distrust, Interoceptive Awareness, and Maturity Fears. The TAS-20 correlated significantly only with Interpersonal Distrust in the matched comparison group, and only with Ineffectiveness and Interpersonal Distrust in the female student group. The results suggest that alexithymia is related to several psychological traits that are characteristic of patients with eating disorders and thought to play a role in the development of the disorders but is unrelated to attitudes and behaviors concerning abnormal eating and body weight and shape.

Mode of food intake reduction in Lewis rats with indomethacin-induced ulcerative ileitis

The mechanism of anorexia in inflammatory bowel disease is poorly understood. To gain insight into possible pathophysiologic mechanisms, the feeding indices and food intake were studied in an animal model of Crohn's disease. The anorexia of indomethacin-induced ulcerative ileitis was compared with that of the well-known anorexia of total parenteral nutrition (TPN). Forty-five female Lewis rats were randomized to four groups: Control, Indomethacin, Indomethacin + TPN, and TPN. Feeding indices and food intake were continuously measured using the Automated Computerized Rat Eater Meter. Interleukin-1 alpha (IL-1 alpha), tumor necrosis factor-alpha (TNF-alpha), prostaglandin E2 (PGE2), and leukotriene B4 (LTB4) were assayed in plasma, mononuclear cell culture, or ileum to determine their role in mediating anorexia. In the TPN group, spontaneous food intake (SFI) decreased (52%; p < 0.05), primarily via reduction in meal number (MN, 54%; p < 0.05) and, to a lesser extent, meal size (MZ, 35%; p < 0.05). In comparison, in the Indomethacin group SFI decreased (74%; p < 0.05) primarily via reduction in MZ (67%, p < 0.05); MN also decreased but to a lesser extent (27%; p < 0.05). In the Indomethacin + TPN group, SFI decreased (55%; p > 0.05) primarily via reduction in MN (79%; p < 0.05), whereas MZ decreased slightly (19%; p < 0.05). Only in the Indomethacin group were IL-1 alpha and TNF-alpha detected in the mononuclear cell culture and plasma, respectively. In the Indomethacin group, an inverse correlation existed between MZ and TNF-alpha (p < 0.05). In the Indomethacin group, IL-1 alpha, PGE2, and LTB4 concentrations did not correlate with feeding indices. SFI reduction in this model was mediated primarily via a decrease in MZ. TNF-alpha is proposed to mediate this effect and TPN was shown to overcome the effect on MZ.

Restrained eating among adolescents: dieters are not always bingers and bingers are not always dieters

This study examined individual differences in the relationships among 3 constructs relevant to restrained eating theory-cognitive restraint (dieting), disinhibition (binging), and hunger. Participants were 421 adolescents (158 male, 255 female, and 8 not indicated). Comparisons among subgroups based on scores on the 3 constructs indicated that there were (a) 2 types of frequent dieters-those who follow theoretical predictions and become disinhibited and those who maintain their restraint; (b) 2 types of bingers-those who engage in dieting-induced binging and those who are hungry and disinhibited; and (c) 2 types of low-hunger eaters-those who suppress their hunger and those who eat before they experience much hunger. Implications of the results for restrained eating theory are discussed.

Anorexia in older persons: epidemiology and optimal treatment

Anorexia and weight loss are common findings in older persons. Over a life-time, normal persons decrease their food intake to counterbalance the decrease in physical activity and resting metabolic rate that occurs with aging. This physiological anorexia of aging increases the propensity to develop pathological anorexia and weight loss when an older person develops either a medical or psychological illness. The physiological anorexia of aging is due to a decreased opioid (dynorphin) feeding drive and an increase in the satiating effect of the gastrointestinal hormone, cholecystokinin. Nitric oxide deficiency may play a role in the early satiation commonly seen in older persons. A variety of social, psychological and medical conditions can lead to pathological anorexia. Depression is the most common cause of weight loss and anorexia in older persons. A number of conditions such as cancer and rheumatoid arthritis produce their anorectic and wasting effects by releasing cytokines. An idiopathic pathological senile anorexia has been characterised which also appears to be a cytokine-dependent syndrome. Early screening for malnutrition is a cornerstone of the management of anorexia; the Mini Nutritional Assessment is a well validated screening tool available for this purpose. Aggressive use of caloric supplements, enteral tube feeding and peripheral parenteral nutrition all have a role in the early management of anorexia. Numerous drugs (growth hormone, megestrol, cyproheptadine, tetrahydrocannabinol, anabolic steroids, prokinetic agents and antidepressants) have been utilised to treat the anorexia of aging with varying success.

An alternating treatments comparison of two intensive interventions for food refusal

We compared two treatment packages involving negative reinforcement contingencies for 3 children with chronic food refusal. One involved physically guiding the child to accept food contingent on noncompliance, whereas the other involved nonremoval of the spoon until the child accepted the presented food. Subsequent to baseline, an alternating treatments comparison was implemented in a multiple baseline design across subjects. After each child had been exposed to at least nine sessions of each treatment condition and percentage of bites accepted had increased to at least 80%, the child's caregivers selected the preferred treatment package. The results indicated that both treatments were effective in establishing food acceptance. However, physical guidance was associated with fewer corollary behaviors, shorter meal durations, and parental preference.

[Anorexic and pseudoanorexic child]

After having conducted and examined an extensive six-year survey of 1372 children (758 females and 614 males, from newly born babies to 12 year olds), the Authors evaluate the importance of anorexy; in fact, it is one of the most frequent reasons for parents taking their children to a pediatrician, as they often see it as a "problem" even when it may not be the case. It is wise not to underestimate the importance of anorexy and the Authors set down some guidelines including the research into the symptoms which may lead us to organic forms, the evaluation of the child's auxologic and nutritional state and an analysis of the existing relationship between mother and child. Defining the most frequent forms of anorexy as primary, they advise carrying out a diagnosis of this type only after the presence of other secondary forms has been excluded, especially in the first year of life. Besides the etiologic therapy used for the secondary forms and some "treatments" (therapy) which act as placebos, the Authors highlight that the real care to primary anorexy lies in the child's dialogue with his/her parents.

Refractory hypothalamic adenylate cyclase in anorectic tumor-bearing rats: implications for NPY-induced feeding

Although isoproterenol stimulated adenylate cyclase activity in hypothalamic membranes taken from freely-feeding, food-restricted or nonanorectic tumor-bearing rats, the response was greatly reduced in anorectic tumor-bearing rats. The addition of NPY to the membrane preparation inhibited adenylate cyclase activity in hypothalamus taken from freely-feeding and food-restricted rats, but NPY-inhibitory activity was significantly reduced in both groups of tumor-bearing rats. These results suggest that cyclic AMP formation is refractory in anorectic tumor-bearing rats, and that NPY-induced inhibition of hypothalamic adenylate cyclase is reduced in tumor-bearing rats prior to the onset of significant anorexia. Therefore, NPY-induced feeding may be reduced in tumor-bearing organisms due to a dysfunction in the cyclic AMP second messenger system.

The hazards of using a child as an interpreter

When a language barrier prevents communication with immigrant parents, there may be a temptation to use a bilingual child as an interpreter. We report a possible hazard.

Nutritional assessment of drug addicts

OBJECTIVE

To discern if factors such as organic pathology, sex, duration and/or intensity of drug addiction, alcohol abuse, hepatitis B infection, anorexia with poor food and drink consumption, or disturbance of social and familial networks, are related to an impaired nutritional status in hospitalized drug addicts.

DESIGN

Cross-sectional prospective study.

SETTING

Detoxication unit and internal medicine unit of a university hospital.

PATIENTS

140 drug addicts without acute organic pathology and 18 with acute organic pathology related to drug addiction. The immunological study was compared with a control group composed of 50 healthy and well-nourished individuals (26 women and 24 men), age-matched with our patients.

RESULTS

Drug addicts without organic pathology were under-nourished: 92.4% weighed under the mean weight for the population and 55.7% had had a weight loss above 5%. The distribution of mid-upper arm circumference (MUAC), triceps skinfold (TSF) measurement and mid-arm muscle area (MAMA) compared with the percentiles for the population showed a shift towards lower values. We found a high percentage of patients with a high lymphocyte count (55%). Despite the high lymphocyte count, delayed hypersensitivity was depressed in our patients. Of our patients, 66.4% exhibited anorexia at admission. The mean calorific intake was 978 +/- 89 kcal/day in females and 1265 +/- 64 kcal/day in males. However, in most cases, malnutrition (usually marasmus-like malnutrition) was not very severe; only 30% of the drug addicts weighed less than 80% of the mean weight for the population, or admitted to a weight loss above 10%, and by subjective nutritional assessment, only 18% were deeply malnourished. Otherwise, the nutritional status was very poor in drug addicts with acute organic pathology. We also found a worse nutritional status in our patients related to female sex, intensity of drug addiction, anorexia with poor food and drink consumption, and disturbance of the social and familial networks.

CONCLUSIONS

Many drug addicts suffer from calorie and protein malnutrition. This mainutrition is related to female sex, intensity of drug addiction, anorexia and poor food and drink consumption, and disturbance of the social and familial links. Acute organic pathology leads to a significant worsening of the nutritional status of drug addicts.

Behavioral conditioning of lipopolysaccharide-induced anorexia

One manifestation of the acute phase response, sickness behavior, is now considered an important response in the organism's overall attempt to reinstate homeostasis. This report aimed to determine whether the sickness behavior of anorexia was conditionable using the conditioned taste aversion paradigm. To investigate this phenomenon, lipopolysaccharide (LPS) (100 micrograms/kg) was used as the unconditioned stimulus, and was paired with a novel 1% saccharin solution (conditioned stimulus). Upon conditioned stimulus representation, the anorectic effects of LPS were observed. These data are consistent with recent literature showing acute phase events to be conditionable.