An integrative quantitative model of factors influencing the course of anorexia nervosa over time

Eating Expectancies in Relation to Eating Disorder Recovery

This study examined the relation between eating expectancies, assessed via the Eating Expectancy Inventory, and eating disorder recovery. Individuals formerly seen for an eating disorder were categorized as having an active eating disorder (n = 53), as partially recovered (n = 15), or as fully recovered (n = 20). The expectancies of these groups were compared to each other and to 67 non-eating disorder controls. Results revealed that three of the five eating expectancies differed across groups. Non-eating disorder controls and fully recovered individuals endorsed similar levels of the expectancies that eating helps manage negative affect, eating is pleasurable and useful as a reward, and eating leads to feeling out of control. Partially recovered individuals looked more similar to active eating disorder cases on these expectancies. The other two expectancies did not differ across groups. Results provide some indication that certain eating expectancies may be associated with eating disorder recovery.

The inter-relationships between vegetarianism and eating disorders among females

When individuals with a suspected or diagnosed eating disorder adopt a vegetarian diet, health care professionals might worry that this choice could function as a socially acceptable way to legitimize food avoidance. Yet only limited research has examined vegetarianism in relation to eating disorders. Our study objectives were to compare individuals with and without an eating disorder history and individuals at different stages of eating disorder recovery on past and current vegetarianism and motivations for and age at becoming vegetarian. Participants were females seen at some point for an eating disorder (n=93) and controls who never had an eating disorder (n=67). Recruitment and data collection for this cross-sectional study occurred in 2007-2008. χ(2) analyses and analyses of variance and covariance were used to examine the research questions. Compared with controls, individuals with an eating disorder history were considerably more likely to ever have been vegetarian (52% vs 12%; P<0.001), to be currently vegetarian (24% vs 6%; P<0.01), and to be primarily motivated by weight-related reasons (42% vs 0%; P<0.05). The three recovery status groups (fully recovered, partially recovered, and active eating disorder) did not differ significantly in percentiles endorsing a history of vegetarianism or weight-related reasons as primary, but they differed significantly in current vegetarianism (33% of active cases, 13% of partially recovered, 5% of fully recovered; P<0.05). Most perceived that their vegetarianism was related to their eating disorder (68%) and emerged after its onset. Results shed light on the vegetarianism-eating disorders relation and suggest intervention considerations for clinicians (eg, investigating motives for vegetarianism).

Olfactory function and alternation learning in eating disorders

Orbitofrontal dysfunction is a prominent feature of obsessive compulsive disorder (OCD). In the present study we assessed orbitofrontal functioning in eating disorders (EDs) which share many features with OCD. For this purpose we studied female adolescent inpatients with anorexia nervosa restricting type (n=40), anorexia nervosa binge/purge type (n=23), a normal weight group including patients with either bulimia nervosa or eating disorder not otherwise specified-purging type (n=33), and 20 non-ED control females. Patients were assessed at admission, and when achieving weight restoration and symptom stabilization at discharge, for depression, non-ED, and ED-related OC symptoms. Orbitofrontal functioning was assessed with an alternation learning task, and with a battery assessing olfactory threshold and discrimination. Control females were assessed once. ED patients of all subtypes performed better on olfactory threshold and discrimination, but not on alternation learning, in comparison to healthy controls. More favorable orbitofrontal functioning was associated with greater ED-related obsessionality. No changes were found in olfactory threshold and discrimination between acutely-ill and symptomatically-stabilized patients. The improvement shown in alternation learning from admission to discharge was suggested to reflect a learning effect rather than being an actual change. Our findings suggest that the better orbitofrontal functioning of ED patients in comparison to healthy controls may represent a core feature of the ED that is independent of malnutrition and deranged eating behaviors, but is associated with ED-related obsessionality.

From One Extreme to the Other: Negative Evaluation Anxiety and Disordered Eating as Candidates for the Extreme Female Brain

Simon Baron-Cohen pioneered the idea that different brain types evolved to process information in gender specific ways. Here we expand this approach to looking at eating disorders as a byproduct of the extreme female brain. The incidence of eating disorders is higher among females, and recent findings show that hormones may play a role in eating disorders. We present new evidence from four studies that both an empathizing bias and hyper-mentalizing (as measures of the extreme female brain; EFB) are related to disordered eating and negative evaluation anxiety in women. We also advance the novel hypothesis that concerns about animal welfare (a unique expression of the EFB) may account for the relationship between vegetarianism and eating disorders.

Examining the match between assessed eating disorder recovery and subjective sense of recovery: preliminary findings

This study examined how individuals, clinically assessed as fully or partially recovered from an eating disorder (ED), subjectively perceived themselves in terms of stage of change in the recovery process. Individuals formerly seen for an ED at a Midwestern clinic were recruited. Using validated definitions of recovery, 18 were fully recovered (physical, behavioural and psychological recovery), and 15 were partially recovered (only physical and behavioural recovery); these groups were compared on overall stage of change and confidence related to this stage, dieting stage of change and internality of motivation. The fully and partially recovered groups endorsed being fully recovered (overall and for dieting) at similar rates. There were trends for the fully recovered group seeking change primarily for themselves and being more confident in their stage of change choice. Results have implications for approaches when a client's assessed recovery stage does not match her subjective sense of recovery and for better understanding recovery from an ED.

Fear of food as a treatment target: exposure and response prevention for anorexia nervosa in an open series

OBJECTIVE

Anorexia nervosa (AN) is a severe mental illness with high rates of relapse and rehospitalization. New treatment approaches are needed. We aimed to evaluate the potential utility of addressing eating-related fear in the treatment of AN using psychotherapy techniques known to be effective in the treatment of anxiety disorders and obsessive compulsive disorder, namely exposure therapy and response prevention.

METHOD

We developed a brief treatment intervention for AN (AN-EXRP) and evaluated its effects in an open series of nine individuals with AN towards the end of acute weight restoration. We focused on eating behavior as the primary outcome, as it is related both to anxiety and to longer term course.

RESULTS

Change in anxiety with AN-EXRP was associated with greater caloric intake.

DISCUSSION

These findings support the anxiety-centered model of AN and suggest the potential utility of further developing this treatment approach.

Objectified body consciousness in relation to recovery from an eating disorder

In Western society, the feminine body has been positioned as an object to be looked at and sexually gazed upon; thus, females often learn to view themselves as objects to be observed (i.e., objectified body consciousness (OBC)). This study examined the relation between OBC and eating disorder recovery by comparing its components across non-eating disorder controls, fully recovered, partially recovered, and active eating disorder cases. Results revealed that non-eating disorder controls and fully recovered individuals had similarly low levels of two components of OBC, body surveillance and body shame. Partially recovered individuals looked more similar to those with an active eating disorder on these constructs. The third component of OBC, control beliefs, and a conceptually similar construct, weight/shape self-efficacy, did not differ across groups. Results provide support for the importance of measuring aspects of self-objectification, particularly body surveillance and body shame, across the course of an eating disorder.

Neuropsychological psychopathology measures in women with eating disorders, their healthy sisters, and nonrelated healthy controls

OBJECTIVE

To assess the familial influence on neuropsychological dysfunction in eating disorders (ED) patients by comparing 16 patients with restricting type anorexia nervosa (AN-R), 18 patients with bingeing purging type anorexia nervosa, 20 patients with bulimia nervosa binge-purge type, 21 of the patients' nonaffected sisters, and 20 nonrelated healthy controls.

METHODS

Self-report questionnaires assessing psychopathology and 2 computerized cognitive tasks measuring hemispheric asymmetry for language and visuospatial abilities were administered to all participant groups.

RESULTS

On the self-report questionnaires, ED patients scored significantly more pathological than the healthy controls, whereas the healthy sisters were similar to the nonrelated healthy control group. For both of the computerized tasks, the behavior pattern of the sisters was similar to that of all, or most ED groups, and were significantly different from the nonrelated healthy controls. In addition, AN-R patients performed significantly worse on the visuospatial task than the other ED groups.

CONCLUSIONS

The dissociation between the performance on the cognitive tasks and psychopathology measures in healthy sisters, when compared to the ED and nonrelated healthy control groups, suggests that disturbances in neurocognitive functioning in ED patients are not necessarily the result of ED-related dysfunction. Rather, this may indicate general individual differences in cognitive processes that may run in families irrespective of the ED condition of the family member. The findings, with respect to the AN-R patients, support a neurocognitive continuum model of EDs in which AN-R represents the most severe form of the illness.

Prevalence and associated factors with body image dissatisfaction among adults in southern Brazil: a population-based study

We investigated the prevalence of body image dissatisfaction (BID) and associated factors in Florianopolis, Brazil. BID was analyzed in a sample (N=1720) of adults through the Figure Rating Scale. The independent variables were sociodemographic factors, health behaviors, and morbidities. A multinomial logistic regression analysis was used. More men (14.2%) than women (6.1%) presented BID by being lighter than ideal (LI). Conversely, more women (66.6%) than men (46.3%) showed BID by being heavier than ideal (HI). BID by being HI was higher among older women, those with high BMI and those with a partner. In men, lower BMI and the presence of common mental disorders were associated with BID due to being LI. Advanced ages, alcohol abuse, physical inactivity, and obesity were associated with BID due to being HI. We must consider different public health interventions for men and women to reduce BID in Brazilian adults.

Rationale for the application of exposure and response prevention to the treatment of anorexia nervosa

OBJECTIVE

Anorexia nervosa (AN) is a life threatening and difficult to treat illness with a high relapse rate. Current treatments are inadequate and new approaches to treatment are needed.

METHOD

We review the data on anxiety in AN, the relationship between anxiety disorders and AN, and the use of Exposure and Response Prevention in treatment.

RESULTS

The overlap between AN and anxiety disorders suggest a model of AN in which baseline anxiety features yield eating related fears, avoidance behaviors, and ritualized safety behaviors that promote the underweight state and the perpetuation of the disorder. We propose an Exposure and Response Prevention treatment to prevent relapse in AN.

DISCUSSION

Overlap between AN and anxiety disorders suggests that Exposure and Response Prevention may be a new and beneficial approach to preventing relapse in individuals with AN.

Coping and social support as potential moderators of the relation between anxiety and eating disorder symptomatology

Trait anxiety and eating disorder (ED) symptomatology are often thought to be inextricably linked. Because anxiety often precedes an ED, predicts poor outcome, and persists even after recovery from an ED, it is important to examine whether certain factors have the ability to potentially attenuate anxiety's effect on eating pathology. In the current study, we examined two possible moderating factors: coping skills and social support. Participants were 96 females seen at one point for an ED at a Midwestern clinic, including 53 with a current ED diagnosis and 43 who no longer met criteria for an ED and who were at varying levels of recovery. Results revealed that emotion-oriented coping moderated the relation between anxiety and ED symptoms. Individuals who were high in trait anxiety and who reported low levels of emotion-oriented coping reported much lower levels of ED symptomatology than those with high trait anxiety and high emotion-oriented coping. Contrary to our hypotheses, task-oriented coping, avoidance-oriented coping, and perceived social support (total, family, friend, and special person) did not emerge as moderators of the relation between trait anxiety and eating pathology. Results provide growing support that factors that interact with anxiety can lessen anxiety's effect on eating pathology. Implications for treatment and future directions are discussed.

The interaction between perinatal factors and childhood abuse in the risk of developing anorexia nervosa

BACKGROUND

Perinatal factors seem to be implicated in the pathogenesis of anorexia nervosa (AN) and may be involved in the programming of stress response systems in humans. Our aim was to explore one of the possible pathways to explain the association between perinatal complications and a psychiatric disorder. In particular, we tested the hypothesis that neonatal immaturity may confer an enhanced vulnerability to AN after exposure to a severe stressful event, such as childhood abuse.

METHOD

The sample was composed of subjects who took part in a prevalence study carried out on a representative sample of the general population and cases of AN referred to an out-patient specialist unit. All subjects (n=663) were born in the two obstetric wards of Padua Hospital between 1971 and 1979. We analysed data using both a case-control and a cohort design.

RESULTS

We found that functional signs of neonatal dysmaturity, but not a low birthweight or prematurity, had a significant additive interaction with childhood abuse in determining the risk for this illness. In normal subjects, but not in subjects with AN, neonatal dysmaturity was associated with being small, short or thin for gestational age at birth.

CONCLUSIONS

The synergistic effect of neonatal dysmaturity and childhood abuse in increasing the risk for AN provides evidence for the hypothesis that a prenatal programming of stress response systems can result in an impairment of the individual's resilience to severe stressful events.

Irreversibility of cardiac autonomic dysfunction in female adolescents diagnosed with anorexia nervosa after short- and long-term weight gain

Anorexia nervosa (AN) patients may present with cardiac autonomic system dysfunction. Power spectral analysis of heart rate variability (HRV) is a reliable noninvasive examination for the quantitative assessment of the central sympathovagal interaction that modulates cardiovascular autonomic function. In the present study, HRV parameters were assessed in female adolescent AN inpatients in the malnourished phase at admission, at discharge when achieving weight restoration, and 24-36 months after discharge, when considered remitted. Nineteen normal-weight female controls were similarly assessed. Spectral analysis of HRV was done with the fast Fourier transform algorithm. At admission and discharge, patients underwent routine laboratory examinations and responded to questionnaires assessing eating-related preoccupations, behaviors, and personality attributes, depression and anxiety. Compared with the controls, AN patients had significantly lower heart-rate and HRV, lower total power and low frequency components, elevated high frequency components, and decreased low to high frequency power ratio as assessed with the power spectral analysis at all three evaluation points. These disturbances were not correlated with the baseline laboratory and psychometric measures. Our preliminary findings suggest that female adolescent AN inpatients may have a cardiovascular autonomic dysfunction in the form of vagal abnormality present not only in malnourished patients, but also persisting following short-term and long-term weight restoration.

Defining recovery from an eating disorder: Conceptualization, validation, and examination of psychosocial functioning and psychiatric comorbidity

Conceptually, eating disorder recovery should include physical, behavioral, and psychological components, but such a comprehensive approach has not been consistently employed. Guided by theory and recent recovery research, we identified a "fully recovered" group (n = 20) based on physical (body mass index), behavioral (absence of eating disorder behaviors), and psychological (Eating Disorder Examination-Questionnaire) indices, and compared them with groups of partially recovered (n = 15), active eating disorder (n = 53), and healthy controls (n = 67). The fully recovered group was indistinguishable from controls on all eating disorder-related measures used, while the partially recovered group was less disordered than the active eating disorder group on some measures, but not on body image. Regarding psychosocial functioning, both the fully and partially recovered groups had psychosocial functioning similar to the controls, but there was a pattern of more of the partially recovered group reporting eating disorder aspects interfering with functioning. Regarding other psychopathology, the fully recovered group was no more likely than the controls to experience current Axis I pathology, but they did have elevated rates of current anxiety disorder. Results suggest that a stringent definition of recovery from an eating disorder is meaningful. Clinical implications and future directions regarding defining eating disorder recovery are discussed.

Trait anxiety in children and adolescents with anorexia nervosa

In this study of trait anxiety in children and adolescents with anorexia nervosa, a consecutive series of 23 newly admitted children and adolescents with anorexia nervosa was studied by use of the State-Trait-Anxiety-Inventory, the Eating Disorders Inventory (EDI), the Social Phobia and Anxiety Inventory for Children (SPAI-C), and a structured psychiatric interview (DIPS: Diagnostisches Interview bei psychischen Störungen). In addition, clinical diagnoses were taken from the files. Trait anxiety was significantly increased at the time of admission and social phobia was present in a large proportion of the patients. Specific eating disorder psychopathology as measured by the EDI was significantly associated with trait anxiety. There were no clinical diagnoses (according to the International Classification of Diseases - Tenth Revision) of anxiety disorders. Features of anxiety are very common in young patients with anorexia nervosa and closely linked to specific psychopathology. Anxiety disorders need careful evaluation in these patients.