Eating disorders

Stereotactic surgery for eating disorders

EATING DISORDERS (EDS) ARE A GROUP OF SEVERELY IMPAIRED EATING BEHAVIORS, WHICH INCLUDE THREE SUBGROUPS: anorexia nervosa (AN), bulimia nervosa (BN), and ED not otherwise specified (EDNOS). The precise mechanism of EDs is still unclear and the disorders cause remarkable agony for the patients and their families. Although there are many available treatment methods for EDs today, such as family therapy, cognitive behavioral therapy, medication, psychotherapy, and so on, almost half of the patients are refractory to all current medical treatment and never fully recover. For treatment-refractory EDs, stereotactic surgery may be an alternative therapy. This review discusses the history of stereotactic surgery, the modern procedures, and the mostly used targets of stereotactic surgery in EDs. In spite of the limited application of stereotactic surgery in ED nowadays, stereotactic lesion and deep brain stimulation (DBS) are promising treatments with the development of modern functional imaging techniques and the increasing understanding of its mechanism in the future.

Forebrain networks and the control of feeding by environmental learned cues

The motivation to eat is driven by a complex sum of physiological and non-physiological influences computed by the brain. Physiological signals that inform the brain about energy and nutrient needs are the primary drivers, but environmental signals unrelated to energy balance also control appetite and eating. The two components could act in concert to support the homeostatic regulation of food intake. Often, however, environmental influences rival physiological control and stimulate eating irrespective of satiety, or inhibit eating irrespective of hunger. If persistent, such maladaptive challenges to the physiological system could lead to dysregulated eating and ultimately to eating disorders. Nevertheless, the brain mechanisms underlying environmental contribution in the control of food intake are poorly understood. This paper provides an overview in recent advances in deciphering the critical brain systems using rodent models for environmental control by learned cues. These models use associative learning to compete with the physiological control, and in one preparation food cues stimulate a meal despite satiety, while in another preparation fear cues stop a meal despite hunger. Thus far, four forebrain regions have been identified as part of the essential cue induced feeding circuitry. These are telencephalic areas critical for associative learning, memory encoding, and decision making, the amygdala, hippocampus and prefrontal cortex and the lateral hypothalamus, which functions to integrate feeding, reward, and motivation. This circuitry also engages two orexigenic peptides, ghrelin and orexin. A parallel amygdalar circuitry supports fear cue cessation of feeding. These findings illuminate the brain mechanisms underlying environmental control of food intake and might be also relevant to aspects of human appetite and maladaptive overeating and undereating.

Secretive food concocting in binge eating: test of a famine hypothesis

OBJECTIVE

Food concocting, or making strange food mixtures, is well documented in the famine and experimental semistarvation literature and appears anecdotally in rare descriptions of eating disorder (ED) patients but has never been scientifically investigated. Here we do so in the context of binge-eating using a "famine hypothesis of concocting."

METHOD

A sample of 552 adults varying in binge eating and dieting traits completed a Concocting Survey created for this study. Exploratory ED groups were created to obtain predictions as to the nature of concocting in clinical populations.

RESULTS

Binge eating predicted the 24.6% of participants who reported having ever concocted but dietary restraint, independently, even after controlling for binge eating, predicted its frequency and salience. Craving was the main motive. Emotions while concocting mirrored classic high-arousal symptoms associated with drug use; while eating the concoctions were associated with intensely negative/self-deprecating emotions. Concocting prevalence and salience was greater in the anorexia > bulimia > BED > no ED groups, consistent with their respectively incrementing dieting scores.

DISCUSSION

Concocting distinguishes binge eating from other overeating and, consistent with the famine hypothesis, is accounted for by dietary restraint. Unlike its adaptive function in famine, concocting could worsen binge-eating disorders by increasing negative effect, shame, and secrecy. Its assessment in these disorders may prove therapeutically valuable.

The use of effective treatments: the case of an adolescent girl with anorexia nervosa in the context of a conversion disorder

The use of empirically supported treatment (EST) has been shown to enhance treatment outcome. The purpose of this case study was to suggest that ESTs further encourage effective reconceptualisation and the ongoing delivery of effective treatment, especially in the case of complex or atypical presentations or response to treatment. This report describes the case of an adolescent girl who underwent Maudsley family-based treatment for anorexia nervosa (AN) for a period of 12 months. Atypical response lead to an understanding of her presentation as representing a primary conversion disorder, within which AN symptoms were conceptualised as another somatic conversion of emotional distress. The report details her clinical presentation and management over the course of her illness. The case offers an important opportunity to explore the central role of the use of ESTs in guiding effective treatment delivery.

Methylation of the glucocorticoid receptor gene promoter in bulimic women: associations with borderline personality disorder, suicidality, and exposure to childhood abuse

OBJECTIVE

To compare levels of methylation of the glucocorticoid receptor (GR) gene (NR3C1) promoter between women with bulimia nervosa (BN) and women with no eating disorder (ED), and also to explore, in women with BN, the extent to which methylation of the GR gene promoter corresponds to childhood abuse, suicidality, or borderline personality disorder (BPD).

METHOD

We measured methylation levels in selected NR3C1 promoter regions using DNA obtained from lymphocytes in 64 women with BN (32 selected as having a history of severe childhood abuse and 32 selected as having no such history) and 32 comparison women with no ED or history of childhood abuse.

RESULTS

Compared to noneating disordered women, women with BN and comorbid BPD (or BN with a history of suicidality) showed significantly more methylation of specific exon 1C sites. There was also a (nonsignificant) result indicative of greater methylation in some 1C sites among women with BN, when compared (as a group) to women with no ED. No parallel effects owing to childhood abuse were observed.

DISCUSSION

Our findings associate BN (when accompanied by BPD or suicidality) with hypermethylation of certain GR exon 1C promoter sites. We discuss theoretical and clinical implications of our findings.

Anorexia nervosa during adolescence and young adulthood: towards a developmental and integrative approach sensitive to time course

Anorexia nervosa is situated at the junction between two time scales, the time scale of adolescence, in which intense physiological and psychological upheavals are occurring over a relatively short period of time, and the time scale of the potentially chronic evolution of the disease over the course of the patient's lifespan. This second time scale links the critical period of adolescence with the pre-morbid period, during which a complex state of vulnerability, often unseen and unheard, combines with different risk factors, which may be isolated, associated, dissociated or concomitant, to produce the emergence of anorexia; it ushers also adolescence into the period of adulthood, flagged with the reorganization that occurs in the course of the healing process (in case of recovery), or pervaded by somatic and mental distress (in cases where the condition becomes chronic). Given the lifespan nature of the disease, it is difficult to differentiate premorbid pathogenic factors from changes resulting from the acute or chronic phases of the illness. It is also difficult to establish straightforward correlations between physiological disturbances and their clinical consequences, or conversely to assume that the restoration of physiological parameters means the disappearance of the underlying mental disorder. Taken together, these observations support an approach to anorexia nervosa that is both developmental and integrative, taking into account both the complexity of the pathways involved and the developmental timescales of these pathways. This type of approach can help to adjust therapeutic strategies and thus enhance prognosis, in particular by integrating the temporal parameter into the dynamics of care plans.

Enhancing quality of life in people with disordered eating using an online self-help programme

BACKGROUND

Eating disorders are serious mental illnesses that have a significant effect on afflicted individuals' quality of life. Evidence has shown that they can be improved with treatment. Internet-based interventions are useful in engaging individuals with eating disorders in self-management and treatment. This study aimed primarily to identify the change in quality of life of individuals with disordered eating after participating in an open trial of an Internet-based self-help programme, and compared their quality of life at assessment with that of healthy controls. Factors affecting their quality of life were examined. Secondary outcomes related to symptom improvement were also reported.

METHODS

This study included 194 individuals with disordered eating and 50 healthy controls. The former group was recruited from eating disorder outpatient clinics and treatment units, as well as via information disseminated through various Internet websites, while the healthy controls were recruited from university student newspapers and university campuses. The Medical Outcomes Study Short Form Survey (SF-36v2) was used to assess participants' quality of life. Other measures were used to assess their symptoms and motivational stages of change to recover from an eating disorder. The Wilcoxon signed ranks test and one-way repeated measures ANOVA were used to identify the change in quality of life of individuals with disordered eating from baseline to 1-, 3- and 6-month follow-ups. The Mann-Whitney U test was employed to compare the difference in quality of life between participants with disordered eating and the healthy controls. Spearman rank order correlations were performed to examine the factors associated with quality of life.

RESULTS

The participants with disordered eating had significantly poorer quality of life than the healthy controls in both physical and psychological domains. The factors associated with their poor quality of life included dieting behaviour, use of laxatives, severe eating disorder psychopathology, depression and anxiety. Over a six-month follow-up period, a significant number of participants engaged in self-help behaviours using the Internet-based programme. They experienced improvements in their quality of life, eating disorder psychopathology, depression severity, anxiety level and motivational stages of change.

CONCLUSIONS

Internet-based self-help programmes have the potential to enhance quality of life in individuals with disordered eating and could be useful adjuncts to professional treatment.

Therapeutic options for binge eating disorder

OBJECTIVE

This article addresses the state of the art concerning the treatment of binge eating disorder (BED). Pharmacological and psychotherapeutic strategies, together with issues concerning the involvement in bariatric surgery are considered.

METHOD

A Medline enquiry of published articles was performed using the following keywords: BED, pharmacological treatment, duloxetine, venlafaxine, SSRI, psychotherapy, bariatric surgery; reviews and single-case studies were also analyzed.

RESULTS

Psychological interventions that have shown efficacy in the treatment of Bulimia Nervosa have also been tested in BED with positive results, in particular modified cognitive behavioral therapy, interpersonal therapy and dialectical behavior therapy. In addition pharmacotherapy with SSRIs is successful in transiently reducing binge-eating and body weight; the SNRI duloxetine is effective for reducing binge eating, and global severity of illness with a controversial effect on body weight; both topiramate and sibutramine seem promising, but their use is restricted due to labeling and side effect limitations, respectively. Finally, adequate psychological/pharmacological support can help BED patients obtain positive outcomes from bariatric surgery.

CONCLUSION

Studies on BED treatment are burdened by several limitations as selection biases (e.g. mostly women and overweight), small samples, high drop-out rates and placebo response.

Effect of the planet health intervention on eating disorder symptoms in Massachusetts middle schools, 2005-2008

Introduction

The Planet Health obesity prevention curriculum has prevented purging and abuse of diet pills (disordered weight control behavior [DWCB]) in middle-school girls in randomized trials, but the effects of Planet Health on DWCB when implemented by schools under dissemination conditions are not known.

Methods

Massachusetts Department of Public Health and Blue Cross Blue Shield of Massachusetts disseminated Planet Health as part of the 3-year, Healthy Choices obesity prevention program in middle schools. We conducted an evaluation in 45 schools from fall 2005 to spring 2008. We gathered data from school staff to quantify intervention activities, and we gathered anonymous cross-sectional survey data from students on DWCB at baseline and Year 3 follow-up (n = 16,369). Multivariate logistic analyses with generalized estimating equations examined the effect of intervention activities on odds of students reporting DWCB at follow-up.

Results

Students in schools reaching a high number of youth with Planet Health lessons on reducing television viewing had lower odds of DWCB at follow-up (odds ratio [OR], 0.80 per 100 lesson-exposures; 95% confidence interval [CI], 0.74–0.85). In addition, reduced odds of DWCB at follow-up were found in schools with active staff teamwork (OR, 0.76; 95% CI, 0.66–0.86) and the presence of programs addressing television viewing goals with staff (OR, 0.38; 95% CI, 0.28–0.53).

Conclusion

Combined evidence from efficacy and effectiveness trials and now from dissemination research indicates that appropriately designed obesity prevention programs can achieve DWCB prevention on a large scale.

The severity of ADHD and eating disorder symptoms: a correlational study

BACKGROUND

Attention deficit/hyperactivity disorders (ADHD) and eating disorders (ED) share several clinical features. Research on the association between ADHD and ED is still quite sparse and findings are ambiguous.

METHODS

Correlations between the severity of ADHD key features (Barratt Impulsiveness Scale, and Attention Deficit/Hyperactivity Disorder-Self-Rating questionnaire) and the severity of specific ED symptoms (Structured Interview for Anorexia and Bulimia Nervosa) were examined in 32 female patients diagnosed with ED.

RESULTS

Most correlations between the severity of ADHD features and the severity of ED symptoms were low (r<0.30) and did not reach statistical significance. The only exception was a statistically significant, but counterintuitive association between impulsivity and the avoidance of fattening food.

CONCLUSIONS

The findings in this small sample suggest a weak link between the severity of ADHD key features and the severity of single ED symptoms in female patients with ED. The role of ADHD features for the development, maintenance, and treatment of EDs seems to be intricate and requires further study.

Ghrelin and eating disorders

There is growing evidence supporting a multifactorial etiology that includes genetic, neurochemical, and physiological components for eating disorders above and beyond the more conventional theories based on psychological and sociocultural factors. Ghrelin is one of the key gut signals associated with appetite, and the only known circulating hormone that triggers a positive energy balance by stimulating food intake. This review summarizes recent findings and several conflicting reports on ghrelin in eating disorders. Understanding these findings and inconsistencies may help in developing new methods to prevent and treat patients with these disorders.

Body size over-estimation in women with anorexia nervosa is not qualitatively different from female controls

Over-estimation of body size is a cardinal feature of anorexia nervosa (AN), usually revealed by comparing individuals who have AN with non-AN individuals, the inference being that over-estimation is pathological. We show that the same result can be reproduced by sampling selectively from a single distribution of performance in body size judgement by comparing low BMI individuals with normal BMI individuals. Over-estimation of body size in AN is not necessarily pathological and can be predicted by normal psychophysical biases in magnitude estimation. We confirm this prediction in a dataset from a morphing study in which 30 women with AN and 137 control women altered a photograph of themselves to estimate their actual body size. We further investigated the relative contributions of sensory and attitudinal factors to body-size overestimation in a sample of 166 women. Our results suggest that both factors play a role, but their relative importance is task dependent.

Repeated traumatic experiences in eating disorders and their association with eating symptoms

OBJECTIVE

This study aimed to analyze the association between traumatic experiences (TEs) and eating symptoms and their severity in a healthy group (HG) of students and an eating disorder group (EDG).

METHOD

The HG (N=150) comprised first- and secondyear undergraduate psychology students, the EDG (N=150) day hospital patients. EDG patients were evaluated consecutively when they entered the Day Hospital Eating Disorder Unit. Information on TEs was collected via an ad hoc questionnaire, a semi-structured interview and the first part of The Dissociation Questionnaire (Part I). The Bulimic Investigatory Test Edinburgh was used to evaluate eating symptoms and their severity.

RESULTS

Emotional abuse was the most frequent TE in both groups. In the EDG, TEs occurred more in patients with purging behavior (anorexia nervosa of the binge-eating/purging type, AN-P; and bulimia nervosa of the purging type, BN-P) than in those with AN-R (anorexia nervosa of the restricting type). In patients with purging behavior, TEs often begin in childhood and are repeated. When the severity of eating symptoms in patients with EDs who had suffered repeated TEs was compared with those who had suffered an isolated TE, a tendency towards greater severity of eating symptoms associated with TE repetition was observed.

CONCLUSIONS

The results obtained with respect to the presence and type of TEs in EDs concurred with those of other studies. However, unlike other studies, we found high percentages of childhood TEs in ED subtypes with purging behavior. In these ED subtypes, TEs tended to be more repeated than in ED subtypes with restrictive behavior. Further studies are required to draw conclusions on the effect of the different TEs and their repetition on eating symptoms and their severity.

Integrated prevention of obesity and eating disorders: barriers, developments and opportunities

OBJECTIVE

The serious consequences of obesity and eating disorders (ED), difficulties encountered in treatment and the high prevalence of these conditions are important reasons to develop efforts aimed at their prevention. The implementation of integrated interventions aimed at preventing risk factors for both obesity and ED constitutes a very exciting development. In the present paper we discuss and review the main reasons for an integrated approach to the spectrum of eating- and weight-related problems, which include anorexia nervosa, bulimia nervosa, anorexic and bulimic behaviours, unhealthy dieting practices, body dissatisfaction, binge-eating disorder, overweight and obesity. Given differences between the fields with regard to current perspectives and objectives, key barriers to an integrated approach to prevention are discussed. In order to show the possibilities of development of this approach, we review the main contributions made to date in the fields of both obesity and ED prevention. In particular, environmental approaches in the prevention of obesity and ED are reviewed, given their potential for preventing a broad spectrum of eating- and weight-related problems. Furthermore, several examples of initiatives that have utilized an integrated approach to prevention are discussed.

DESIGN

Narrative review.

CONCLUSIONS

We recommend a scenario in which the two fields share knowledge to enhance the difficult work of preventing and treating both ED and obesity.

What can qualitative studies tell us about the experiences of women who are pregnant that have an eating disorder?

OBJECTIVE

pregnancy is a life-stage during which women undergo significant changes to their body and can feel acute responsibility for the development and well-being of the fetus. A synthesis of qualitative studies was conducted to increase our understanding of pregnancy experiences among women with an eating disorder.

DESIGN

a systematic search of eight electronic databases was carried out to identify relevant investigations. Studies were appraised by two authors. Data were combined using framework analysis. From 459 references, seven papers were included in the review.

FINDINGS

an overriding concept of inner turmoil transpired from the synthesis. This personal conflict related to the fear and guilt expressed by interviewees and stemmed from their association of self-worth with their body, concerns about their child's health and worries about others' response to their eating and weight control practices.

KEY CONCLUSIONS

participants reported vacillating between wanting to do the best for their child, being motivated by social pressures and feeling the need to control their body for self-preservation purposes. This created the inner turmoil they experienced while pregnant.

IMPLICATIONS FOR PRACTICE

midwives should be sensitive to the possibility of an eating disorder among pregnant women. In such cases, practitioners could act as a conduit for any assistance required, guiding these mothers towards appropriate nutritional and psychological support. To do this, professionals must have knowledge of such conditions and be aware of services available for women disclosing disordered eating behaviours.

Growth hormone level at admission and its evolution during refeeding are predictive of short-term outcome in restrictive anorexia nervosa

The growth hormone (GH)–insulin-like growth factor-1 (IGF-1) axis is dramatically altered in patients with anorexia nervosa (AN). The aim of the present study was to investigate whether GH and IGF-1 could be predictors of outcome in patients with a restrictive form of AN. Blood levels of GH, IGF-1, adipocytokines, ghrelin, insulin, glucose, and sex and thyroid hormones were measured in eleven women inpatients with AN and in ten healthy women controls. Three stages were compared during refeeding: admission (T0), when BMI reached 16 kg/m2 (T1) and at discharge when BMI reached 17.5 kg/m2 (T2). Clinical status was assessed 6 months after discharge from hospital (T3), and remission was defined by the maintenance of a BMI > or = 17.5 kg/m2. AN patients in remission (AN-R; n 6) had significantly higher GH levels at admission than those who relapsed (AN-NR; n 5) (P < 0.05). During refeeding (delta = T2 - T0), the AN-R group differed from the AN-NR group only by both GH level decrease (P < 0.05) and BMI increase (P < 0.05). In multiple regression analysis, delta GH was associated negatively and significantly and delta leptin and delta body fat mass levels were associated positively and significantly with BMI at T3 and explained 88% of its variability (r2 0.88, P < 0.05). The present study suggests that a low GH level at admission and the absence of its decrease after weight recovery could predict short-term relapse in women suffering from a restrictive form of AN.

Out-patient psychological therapies for adults with anorexia nervosa: randomised controlled trial

BACKGROUND

Very limited evidence is available on how to treat adults with anorexia nervosa and treatment outcomes are poor. Novel treatment approaches are urgently needed.

AIMS

To evaluate the efficacy and acceptability of a novel psychological therapy for anorexia nervosa (Maudsley Model of Anorexia Nervosa Treatment for Adults, MANTRA) compared with specialist supportive clinical management (SSCM) in a randomised controlled trial.

METHOD

Seventy-two adult out-patients with anorexia nervosa or eating disorder not otherwise specified were recruited from a specialist eating disorder service in the UK. Participants were randomly allocated to 20 once weekly sessions of MANTRA or SSCM and optional additional sessions depending on severity and clinical need (trial registration: ISRCTN62920529). The primary outcomes were body mass index, weight and global score on the Eating Disorders Examination at end of treatment (6 months) and follow-up (12 months). Secondary outcomes included: depression, anxiety and clinical impairment; neuropsychological outcomes; recovery rates; and additional service utilisation.

RESULTS

At baseline, patients randomised to MANTRA were significantly less likely to be in a partner relationship than those receiving SSCM (3/34 v. 10/36; P<0.05). Patients in both treatments improved significantly in terms of eating disorder and other outcomes, with no differences between groups. Strictly defined recovery rates were low. However, MANTRA patients were significantly more likely to require additional in-patient or day-care treatment than those receiving SSCM (7/34 v. 0/37; P = 0.004).

CONCLUSIONS

Adults with anorexia nervosa are a difficult to treat group. The imbalance between groups in partner relationships may explain differences in service utilisation favouring SSCM. This study confirms SSCM as a useful treatment for out-patients with anorexia nervosa. The novel treatment, MANTRA, designed for this patient group may need adaptations to fully exploit its potential.

[Eating disorders: state of the art research and future challenges]

Eating disorders are a common mental disorder during adolescence and young adulthood. While prevalence rates of eating disorders dramatically increased during the second half of the last century, these rates have remained relatively stable over the last 20 years. According to ICD-10 eating disorders are diagnostically categorized as anorexia nervosa, bulimia nervosa and atypical eating disorders or eating disorders not otherwise specified. Concerning the etiology, genetic factors are involved, especially in anorexia nervosa, as well as psychological and sociocultural factors. Evidence-based recommendations are available for the treatment of bulimia nervosa and binge eating disorder and in this context cognitive behavioral therapy is seen as the first choice. In contrast, the state of knowledge concerning the treatment of anorexia nervosa is still limited, especially concerning effective treatments for adults. Recent data only provide evidence for the effectiveness of family therapy for adolescents. Due to the lack of high quality studies, research on therapy for anorexia nervosa is a future challenge.

A public health approach to eating disorders prevention: it's time for public health professionals to take a seat at the table

BACKGROUND

The societal burden of eating disorders is clear, and though there is a compelling need for a public health approach to eating disorders prevention, public health professionals have yet to take up the challenge.

DISCUSSION

The article lays out an argument for what steps need to be taken to bring a public health approach to eating disorders prevention. First, stock is taken of what the field has achieved so far, using tools from the prevention science literature, and, second, a research plan of action is offered that plays to the unique strengths of public health, drawing on a triggers-to-action framework from public health law. Minimal participation was found from public health professionals in eating disorders prevention research, and the vast majority of prevention research to date was found to be concentrated within the disciplines of psychology and psychiatry. Extreme disciplinary concentration of the research has led to a preponderance of individually targeted prevention strategies with little research focused on environmental targets, particularly at the macro level. New environmental initiatives are now emerging, such as a government-sponsored mass media anti-dieting campaign, and legal bans on extremely thin models in advertising, but for the most part, they have yet to be evaluated. A triggers-to-action framework, which focuses on evidentiary base, practical considerations, and political will, developed in public health law provides a basis for a strategic research plan for a public health approach to eating disorders prevention.

SUMMARY

There is enormous potential for growth in the scope and diversity of eating disorder prevention research strategies, particularly those targeting the macro environment. A public health approach will require a strategic plan for research that leverages the macro environment for prevention. The full engagement of public health professionals will bring to the field the much broader range of preventive strategies and perspectives needed to tackle the problem of eating disorders.

Bindungsmuster, Figurzufriedenheit und auffälliges Essverhalten bei 13- bis 18-jährigen weiblichen und männlichen Jugendlichen

Als potentielle Risikofaktoren für die Entwicklung von Essstörungen sind unsichere Bindung sowie Unzufriedenheit mit dem eigenen Körper bekannt. Diese Studie untersucht den Zusammenhang von Bindungsmustern, Figurzufriedenheit und Essverhalten bei einer nicht-klinischen Stichprobe von Jugendlichen beiderlei Geschlechts. Folgende Variablen wurden bei 13- bis 18-jährigen Mädchen und Jungen (n = 851) an neun Schulen in Jena (Thüringen) erhoben: Bindungsmuster (dt. Version der Adult Attachment Scale, AAS), Figurzufriedenheit (Stunkard Skalen) und Essverhalten (dt. Version des Eating Attitudes Test, EAT-26D). In einem Gesamtmodell stellt die Einschätzung zu dick zu sein das größte Risiko für die Entwicklung einer Essstörung dar (OR = 8,9), gefolgt vom weiblichen Geschlecht (OR = 3,9), Übergewicht (OR = 3,4) sowie unsicherer Bindung (OR = 2,6). Die Ergebnisse bestätigen den positiven Zusammenhang zwischen Bindungsmuster, Figurzufriedenheit und Essverhalten auch für eine jugendliche, nicht-klinische Stichprobe von Jungen und Mädchen und ergeben damit wichtige Implikationen für primär- und sekundärpräventive Interventionen.

Genome-wide association analysis of eating disorder-related symptoms, behaviors, and personality traits

Eating disorders (EDs) are common, complex psychiatric disorders thought to be caused by both genetic and environmental factors. They share many symptoms, behaviors, and personality traits, which may have overlapping heritability. The aim of the present study is to perform a genome-wide association scan (GWAS) of six ED phenotypes comprising three symptom traits from the Eating Disorders Inventory 2 [Drive for Thinness (DT), Body Dissatisfaction (BD), and Bulimia], Weight Fluctuation symptom, Breakfast Skipping behavior and Childhood Obsessive-Compulsive Personality Disorder trait (CHIRP). Investigated traits were derived from standardized self-report questionnaires completed by the TwinsUK population-based cohort. We tested 283,744 directly typed SNPs across six phenotypes of interest in the TwinsUK discovery dataset and followed-up signals from various strata using a two-stage replication strategy in two independent cohorts of European ancestry. We meta-analyzed a total of 2,698 individuals for DT, 2,680 for BD, 2,789 (821 cases/1,968 controls) for Bulimia, 1,360 (633 cases/727 controls) for Childhood Obsessive-Compulsive Personality Disorder trait, 2,773 (761 cases/2,012 controls) for Breakfast Skipping, and 2,967 (798 cases/2,169 controls) for Weight Fluctuation symptom. In this GWAS analysis of six ED-related phenotypes, we detected association of eight genetic variants with P < 10(-5) . Genetic variants that showed suggestive evidence of association were previously associated with several psychiatric disorders and ED-related phenotypes. Our study indicates that larger-scale collaborative studies will be needed to achieve the necessary power to detect loci underlying ED-related traits.

Anti-neuropeptide Y plasma immunoglobulins in relation to mood and appetite in depressive disorder

Depression and eating disorders are frequently associated, but the molecular pathways responsible for co-occurrence of altered mood, appetite and body weight are not yet fully understood. Neuropeptide Y (NPY) has potent antidepressant and orexigenic properties and low central NPY levels have been reported in major depression. In the present study, we hypothesized that in patients with major depression alteration of mood, appetite and body weight may be related to NPY-reactive autoantibodies (autoAbs). To test this hypothesis, we compared plasma levels and affinities of NPY-reactive autoAbs between patients with major depression and healthy controls. Then, to evaluate if changes of NPY autoAb properties can be causally related to altered mood and appetite, we developed central and peripheral passive transfer models of human autoAbs in mice and studied depressive-like behavior in forced-swim test and food intake. We found that plasma levels of NPY IgG autoAbs were lower in patients with moderate but not with mild depression correlating negatively with the Montgomery-Åsberg Depression Rating Scale scores and with immobility time of the forced-swim test in mice after peripheral injection of autoAbs. No significant differences in NPY IgG autoAb affinities between patients with depression and controls were found, but higher affinity of IgG autoAbs for NPY was associated with lower body mass index and prevented NPY-induced orexigenic response in mice after their central injection. These data suggest that changes of plasma levels of anti-NPY autoAbs are relevant to altered mood, while changes of their affinity may participate in altered appetite and body weight in patients with depressive disorder.

Hyperactivity in anorexia nervosa: warming up not just burning-off calories

Excessive physical activity is a common feature in Anorexia Nervosa (AN) that interferes with the recovery process. Animal models have demonstrated that ambient temperature modulates physical activity in semi-starved animals. The aim of the present study was to assess the effect of ambient temperature on physical activity in AN patients in the acute phase of the illness. Thirty-seven patients with AN wore an accelerometer to measure physical activity within the first week of contacting a specialized eating disorder center. Standardized measures of anxiety, depression and eating disorder psychopathology were assessed. Corresponding daily values for ambient temperature were obtained from local meteorological stations. Ambient temperature was negatively correlated with physical activity (p = −.405) and was the only variable that accounted for a significant portion of the variance in physical activity (p = .034). Consistent with recent research with an analogous animal model of the disorder, our findings suggest that ambient temperature is a critical factor contributing to the expression of excessive physical activity levels in AN. Keeping patients warm may prove to be a beneficial treatment option for this symptom.

Clinical and temperamental correlates of body image disturbance in eating disorders

OBJECTIVE

Although body image disturbance (BID) is considered a core symptom in anorexia nervosa (AN) and bulimia nervosa (BN), little is known about its psychopathological correlates. The present study aimed at analysing the correlation of aspects of BID with psychopathological and temperamental characteristics.

METHOD

A sample of 1288 patients (538 AN and 750 BN) were assessed through a structured diagnostic interview, the Eating Disorders Inventory and Tridimensional Personality Questionnaire. Cognition of body image distortion, weight checking, fear of weight gain and body dissatisfaction were assessed by specific questions during the interview.

RESULTS

Various aspects of BID formed similar, but not identical, dimensions in AN and BN. In both groups, anticipatory anxiety and interoceptive awareness were significantly and independently associated with body image distortion, whereas ineffectiveness was associated with weight checking.

DISCUSSION

Body image disturbance is a multidimensional characteristic linked to psychological features, such as anticipatory anxiety, ineffectiveness and interoceptive awareness. These findings have scientific and treatment implications, and should be considered by clinicians in adopting successful treatment strategies.

Anorexia nervosa: treatment expectations - a qualitative study

BACKGROUND

Anorexia nervosa is a serious illness with a high mortality rate, a poor outcome, and no empirically supported treatment of choice for adults. Patients with anorexia nervosa strive for thinness in order to obtain self-control and are ambivalent toward change and toward treatment. In order to achieve a greater understanding of patients' own understanding of their situation, the aim of this study was to examine the expectations of potential anorexic patients seeking treatment at a specialized eating-disorder unit.

METHODS

A qualitative study design was used. It comprised 15 women between 18 and 25 years of age waiting to be assessed before treatment. The initial question was, "What do you expect, now that you are on the waiting list for a specialized eating-disorder unit?" A content analysis was used, and the text was coded, categorized according to its content, and further interpreted into a theme.

RESULTS

FROM THE RESULTS EMERGED THREE MAIN CATEGORIES OF WHAT PARTICIPANTS EXPECTED: "treatment content," "treatment professionals," and "treatment focus." The overall theme, "receiving adequate therapy in a collaborative therapeutic relationship and recovering," described how the participants perceived that their expectations could be fulfilled.

DISCUSSION

Patients' expectations concerning distorted thoughts, eating behaviors, a normal, healthy life, and meeting with a professional with knowledge and experience of eating disorders should be discussed before treatment starts. In the process of the therapeutic relationship, it is essential to continually address patients' motivations, in order to understand their personal motives behind what drives their expectations and their desire to recover.

The effect of gonadal and adrenal steroid therapy on skeletal health in adolescents and young women with anorexia nervosa

Anorexia nervosa (AN) is characterized by subnormal estrogen and dehydroepiandrosterone (DHEA) levels. We sought to determine whether the combination of DHEA + estrogen/progestin is superior to placebo in preserving skeletal health over 18 months in AN. Females with AN, aged 13 to 27 years, were recruited for participation in this double-blind, placebo-controlled, randomized trial. Ninety-four subjects were randomized, of whom 80 completed baseline assessments and received either study drug (oral micronized DHEA 50 mg + 20 µg ethinyl estradiol/0.1 mg levonorgestrel combined oral contraceptive pill [COC] daily; n = 43) or placebo (n = 37). Serial measurements of areal bone mineral density (aBMD), bone turnover markers, and serum hormone concentrations were obtained. Sixty subjects completed the 18-month trial. Spinal and whole-body aBMD z scores were preserved in the DHEA + COC group, but decreased in the placebo group (comparing trends, P = .008 and P = .001, respectively). Bone turnover markers initially declined in subjects receiving DHEA + COC and then returned to baseline. No differences in body composition, adverse effects of therapy, or alterations in biochemical safety parameters were observed. Combined therapy with DHEA + COC appears to be safe and effective for preventing bone loss in young women with AN, whereas placebo led to decreases in aBMD. Dehydroepiandrosterone + COC may be safely used to preserve bone mass as efforts to reverse the nutritional, psychological, and other hormonal components of AN are implemented.

Momentary affect surrounding loss of control and overeating in obese adults with and without binge eating disorder

Research suggests that loss of control (LOC) while eating (the sense that one cannot control what or how much one is eating) is a more salient feature of binge eating than the amount of food consumed. This study examined the unique contributions of LOC and episode size to negative affect surrounding eating episodes in binge eating disorder (BED) and obesity. Twenty-two obese adults with (n = 9) and without (n = 13) BED completed daily records of eating patterns and mood using ecological momentary assessment (EMA). Linear mixed modeling revealed that across groups, greater premeal self-reported LOC was associated with higher premeal negative affect independent of episode size. For individuals with BED, greater premeal self-reported LOC was associated with higher postmeal negative affect, regardless of the amount of food eaten, whereas for obese controls, the combination of LOC and consumption of large amounts of food was associated with lower postmeal negative affect. Results indicate that LOC, but not the quantity of food consumed, is associated with momentary distress related to aberrant eating in BED. Findings also highlight the need for further research investigating the emotional context surrounding aberrant eating in obese individuals without BED.

Anorexia nervosa and the kidney

Anorexia nervosa is a common psychiatric disorder that disproportionately affects adolescents and young adults and is associated with high rates of morbidity and mortality. Anorexia nervosa can affect the kidney in numerous ways, including increased rates of acute kidney injury and chronic kidney disease, electrolyte abnormalities, and nephrolithiasis. Additionally, the diagnosis and treatment of anorexia nervosa-associated kidney diseases are challenging, reflecting complications such as refeeding syndrome, as well as the limitations of serum creatinine level in this population to estimate kidney function and the psychosocial challenges inherent with treating systemic manifestations of psychiatric conditions. In this review, we discuss kidney diseases and kidney-associated conditions that occur in individuals with anorexia nervosa, summarizing many of the challenges in treating patients with this disease.

Do the components of manualized family-based treatment for anorexia nervosa predict weight gain?

OBJECTIVE

Family-based treatment for anorexia nervosa (FBT) has demonstrated efficacy in the treatment of adolescents with anorexia nervosa (AN) in a number of randomized control trials (RCT). The aim of the current research was to determine whether adherence to the key components of the model as outlined in the treatment manual predict weight gain or dropout.

METHOD

The 59 participants were under 19 years and had AN for less than 3 years. Five core treatment objectives and working alliance were measured across 20 sessions of FBT.

RESULTS

The core objectives of parents taking control, being united, not criticizing the patient and externalizing the illness predicted greater weight gain. Sibling support did not predict weight gain. The relationship between therapeutic alliance and weight gain was positive for mothers but negative for fathers. Dropout was predicted by low control and poor maternal-therapeutic alliance.

DISCUSSION

The results of this study lend further support for the efficacy of the FBT, demonstrating that the principles guiding clinical practice are those which lead to weight gain. The finding that parental control is the central predictor of change can also support the development of augmentations to the model.

Body dysmorphic disorder in patients with an eating disorder: prevalence and characteristics

OBJECTIVE

Body dysmorphic disorder (BDD), an abnormal preoccupation with perceived defects in one or more body parts, and eating disorders (ED) share several essential clinical features, making it sometimes difficult to differentiate between the two disorders. The aims of this study were to assess the prevalence of BDD in patients with ED and to compare characteristics of ED patients with and without BDD.

METHOD

We measured dysmorphic appearance concerns and behaviors, ED symptoms, general psychopathology, and quality of life in 158 patients seeking treatment for ED.

RESULTS

Forty-five percent screened positive for BDD. Patients with both disorders (ED + BDD) had significantly more dysmorphic appearance concerns, had more psychopathology, and were dissatisfied with a larger number of body parts than patients with ED only. The differences remained significant even after correcting for severity of eating disorder psychopathology.

DISCUSSION

This finding suggests that BDD is a distinct comorbid disorder in almost half of the patients with ED. It is thus important to recognize and treat the manifestation of BDD in patients with both disorders. Given that the treatment of BDD is different from that of ED, it is important to recognize BDD.

Investigating autism spectrum disorder and autistic traits in early onset eating disorder

OBJECTIVE

To investigate whether young people (8-16 years) with an eating disorder have a higher prevalence of autism spectrum disorder (ASDs) and elevated autistic traits compared to typically developing (TD) peers.

METHOD

Twenty-two participants with early onset eating disorder (EOED) were assessed using standardized ASD measures and compared to IQ matched TD (n = 24) and ASD (n = 20) controls.

RESULTS

An ASD diagnosis was no more common in EOED than in TD controls. However, repetitive and stereotyped behavior was more often observed in the EOED group and, compared to TD controls, there was a trend (p = .07) toward greater autistic social impairment in EOED.

DISCUSSION

Whilst participants with EOED did not show increased ASD prevalence, they did have elevated autistic traits of clinical significance, particularly repetitive and stereotyped behavior. Further work is required to determine whether inflexibility and social difficulties in EOED have identical phenomenology and etiology to those seen in ASD.

Emotional eating in anorexia nervosa and bulimia nervosa

OBJECTIVES

The relationship between emotional states and eating behaviors is complex, and emotional eating has been identified as a possible factor triggering binge eating in bulimia nervosa (BN) and binge eating disorder. Few studies considered emotional eating in patients with anorexia nervosa.

METHODS

The present study evaluated the clinical correlates of emotional eating in 251 eating-disordered (EDs) subjects (70 AN restricting type, 71 AN binge eating/purging type, 110 BN purging type) and in a group of 89 healthy control subjects. Subjects were assessed by means of a clinical interview (Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) and several self-reported questionnaires, including the Emotional Eating Scale (EES).

RESULTS

No significant differences were found between the 3 EDs groups in terms of EES total score, and all patients with ED showed higher EES scores compared with control subjects. Emotional eating was associated with subjective binge eating in AN binge eating/purging type and with objective binge eating in patients with BN. Among patients with AN restricting type, emotional eating was associated with restraint, but this association was lost when controlling for fear of loss of control over eating, which was the principal determinant of restraint.

CONCLUSION

Emotional eating and fear of loss of control over eating are significantly associated with specific eating attitudes and behaviors, according to the different diagnoses. Emotional eating is a relevant psychopathologic dimension that deserves a careful investigation in both anorectic and bulimic patients.

Clinical psychopharmacology of eating disorders: a research update

The paper presents a critical review (with search date 2010) of the major psychotropic medications assessed in eating disorders, namely antipsychotics, antidepressants, mood-stabilizing medications, anxiolytic and other agents. The evidence of efficacy of drug treatments is mostly weak or moderate. In addition, attrition rates are usually higher than for psychotherapies. However, there is support for use of antidepressants, particularly high-dose fluoxetine in bulimia nervosa, and anticonvulsants (topiramate) for binge-eating disorder. Low-dose antipsychotic medication may be clinically useful as adjunct treatment in acute anorexia, particularly where there is high anxiety and obsessive eating-related ruminations and failure to engage, but more trials are needed. Drug therapies such as topiramate and anti-obesity medication may aid weight loss in obese or overweight patients with binge-eating disorder; however, common or potentially serious adverse effects limit their use.

Anorexia nervosa--a noradrenergic dysregulation hypothesis

Anorexia nervosa manifests a wide range of features which cannot fully be explained on the basis of socio-cultural pressures to be thin, nor by starvation, nor dehydration. Evidence is emerging of a significant neurobiological contribution to its aetiology. However there has to date been no explanation for its pathogenesis that integrates the previously identified genetic, neurobiological and socio-cultural contributing factors. In this paper we propose an empirically-based hypothesis that genetically determined noradrenergic dysregulation, interacting with epigenetic factors, leads to high levels of anxiety, impaired neuroplasticity and regional cerebral hypoperfusion. These, in combination, lead to insula dysfunction. The resulting impairment in insula homuncular representation explains the pathognomonic body image distortion. This distortion, combined with high levels of body-focused anxiety, gives rise to intense dieting, noradrenergic precursor depletion, and initial reduction in anxiety. The subsequent rebound exacerbation of anxiety leads to a vicious cycle of maintenance. Novel treatment implications based on this hypothesis are briefly considered.

Figured World of Eating Disorders: Occupations of Illness

Background. The biomedical diagnosis of eating disorders signifies a mental illness with complex physical symptomology. The socio-cultural determinants and impact of eating disorders on daily occupations are not adequately addressed in this classification.

Purpose. This paper introduces the concept of a figured world as a framework for how eating disorders exist in daily activity and social discourse. How occupations become ascribed with meaning generated by an eating disorder will be proposed through the voice of a composite character in the figured world.

Key Issues. Central elements to contextualizing figured worlds include positional identity, self-authoring, and semiotic mediation. The generation of meaning in illness arises from the integration of these elements into this specific figured world.

Implications. The competing agendas of the biomedical model and figured world permit a new understanding of the challenges associated with recovery. For occupational therapists, these challenges require the reattribution of meaning of daily occupations.

Interaction of the BcII glucocorticoid receptor polymorphism and childhood abuse in Bulimia Nervosa (BN): relationship to BN and to associated trait manifestations

We recently documented a gene-environment interaction suggesting that individuals with Bulimia Nervosa (BN) differed from normal eaters as to the combined presence of the low-function allele of the glucocorticoid receptor polymorphism, BcII, and childhood abuse. The present study examined the extent to which any such interaction effect may have been attributable to behavioral impulsivity, sensation seeking, affective instability or depression. We had 174 bulimic and 130 nonbulimic women provide blood for genetic assays, and measured psychopathological traits and childhood abuse using structured interviews and self-report questionnaires. As expected, we observed a significant BcII × abuse interaction indicating genetic and environmental susceptibilities to co-occur significantly more often in bulimic than in nonbulimic individuals. The BcII × abuse interaction was attenuated when levels of depression were accounted for, but was surprisingly unaffected by controls for motoric impulsivity, sensation seeking or affective instability. Our findings suggest that stress-induced alterations in glucocorticoid sensitivity contribute to BN and depressive disturbances--without being associated with the behavioral/affective dysregulation seen in many BN sufferers. We discuss theoretical and clinical implications of these observations.