Anorexia nervosa and sudden death in childhood: clinical data and results obtained from quantitative neurohistological investigations of cortical neurons

Serum neurofilament light concentrations are associated with cortical thinning in anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is characterized by severe emaciation and drastic reductions of brain mass, but the underlying mechanisms remain unclear. The present study investigated the putative association between the serum-based protein markers of brain damage neurofilament light (NF-L), tau protein, and glial fibrillary acidic protein (GFAP) and cortical thinning in acute AN.

METHODS

Blood samples and magnetic resonance imaging scans were obtained from 52 predominantly adolescent, female patients with AN before and after partial weight restoration (increase in body mass index >14%). The effect of marker levels before weight gain and change in marker levels on cortical thickness (CT) was modeled at each vertex of the cortical surface using linear mixed-effect models. To test whether the observed effects were specific to AN, follow-up analyses exploring a potential general association of marker levels with CT were conducted in a female healthy control (HC) sample (n = 147).

RESULTS

In AN, higher baseline levels of NF-L, an established marker of axonal damage, were associated with lower CT in several regions, with the most prominent clusters located in bilateral temporal lobes. Tau protein and GFAP were not associated with CT. In HC, no associations between damage marker levels and CT were detected.

CONCLUSIONS

A speculative interpretation would be that cortical thinning in acute AN might be at least partially a result of axonal damage processes. Further studies should thus test the potential of serum NF-L to become a reliable, low-cost and minimally invasive marker of structural brain alterations in AN.

Glial cells in anorexia

Anorexia is a loss of appetite or an inability to eat and is often associated with eating disorders. However, animal anorexia is physiologically regulated as a part of the life cycle; for instance, during hibernation, migration or incubation. Anorexia nervosa (AN), on the other hand, is a common eating disorder among adolescent females that experience an intense fear of gaining weight due to body image distortion that results in voluntary avoidance of food intake and, thus, severe weight loss. It has been shown that the neurobiology of feeding extends beyond the hypothalamus. The prefrontal cortex (PFC) is involved in food choice and body image perception, both relevant in AN. However, little is known about the neurobiology of AN, and the lack of effective treatments justifies the use of animal models. Glial cells, the dominant population of nerve cells in the central nervous system, are key in maintaining brain homeostasis. Accordingly, recent studies suggest that glial function may be compromised by anorexia. In this review, we summarize recent findings about anorexia and glial cells.

Neuropathological investigation of patients with prolonged anorexia nervosa

OBJECTIVES

Recent neuroimaging studies have indicated that the mesolimbic pathway, known to work as reward neuronal circuitry, regulates cognitive-behavioral flexibility in prolonged anorexia nervosa (AN). Although AN is associated with the highest mortality rate among psychiatric disorders, there have been few neuropathological studies on this topic. This study aims to identify alterations of the reward circuitry regions, especially in the nucleus accumbens (NAcc), using AN brain tissues.

METHODS

The neuronal networks in AN cases and controls were examined by immunohistochemistry directed at tyrosine hydroxylase (TH; dopaminergic neuron marker) and glial fibrillary acidic protein (GFAP; astrocyte marker). We also immunochemically analyzed frozen samples presenting astrogliosis, especially in the NAcc and striatum.

RESULTS

Histologically, neuronal deformation with cytoplasmic shrinkage was seen in reward-related brain regions, such as the orbitofrontal cortex/anterior cingulate cortex. The NAcc showed massive GFAP-positive astrocytes and dot-like protrusions of astrocytes in the shell compartment. In the shell, TH and GFAP immunoreactivities revealed prominent astrogliosis within striosomes, which receive projection from the ventral tegmental area (VTA). The numbers of GFAP-positive astrocytes in the NAcc (P = 0.0079) and VTA (P = 0.0025) of AN cases were significantly higher than those of controls. Strongly immunoreactive 18 to 25 kDa bands, which might represent degradation products, were detected only in the NAcc of AN cases. Clinically, all cases presented cognitive rigidity, which might reflect a deficit of the reward pathway.

CONCLUSION

Our findings suggest impaired dopaminergic innervation between the NAcc and VTA in AN. Functional dysconnectivity in the reward-related network might induce neuropsychiatric symptoms associated with AN.

Metabolic changes in the cingulate gyrus, precuneus, and white matter in anorexia nervosa using multivoxel MR spectroscopy

Background and Purpose

This study aimed to highlight anorexia nervosa‐related metabolic changes in different brain regions with different gray and white matter contents.

Methods

In a prospective study, 25 anorexic patients with mean body mass index (BMI) of 14.79 kg/m² (range 10.04–20.58) were compared with 15 healthy controls with mean BMI of 21.08 kg/m² (range 18.36–27.34). Two‐dimensional magnetic resonance spectroscopic imaging was acquired in the axial plane above the corpus callosum, including frontal, precentral, postcentral, cingular, and parietal regions, as well as the precuneus, each voxel containing gray and white matter.

Results

In the anorexic group, a significant increase of choline/creatine was observed in all brain regions except the precuneus: frontal (p = 0.009), cingulate (p = 0.001), precentral (p = 0.001), postcentral (p = 0.001), and parietal (p = 0.002); and in white and gray matter (p< 0.001). Macromolecules09/creatine was decreased in the following regions: frontal (p = 0.003), cingulate (p< 0.001), precentral (p = 0.004), and precuneus (p = 0.007), and in white and gray matter (p< 0.05). We observed significantly lower values of N‐acetyl aspartate/creatine in the frontal (p < 0.001) and precentral (p< 0.001) regions and in voxels containing more than 50% white matter (p = 0.001); and significantly lower values of myo‐inositol/creatine in the precentral (p = 0.006), postcentral (p< 0.001), and precuneus (p = 0.006) regions.

Conclusions

We observed an increase in choline/creatine in anorexics, possibly reflecting increased cell turnover; a decrease in macromolecules, which was particularly low in the cingulate and precuneus the former being known to be altered in eating disorders; and a decrease in N‐acetyl aspartate/creatine considered as a marker of neuronal density and function.

Differential longitudinal changes of neuronal and glial damage markers in anorexia nervosa after partial weight restoration

Atrophic brain changes in acute anorexia nervosa (AN) are often visible to the naked eye on computed tomography or magnetic resonance imaging scans, but it remains unclear what is driving these effects. In neurological diseases, neurofilament light (NF-L) and tau protein have been linked to axonal damage. Glial fibrillary acidic protein (GFAP) has been associated with astroglial injury. In an attempt to shed new light on factors potentially underlying past findings of structural brain alterations in AN, the current study investigated serum NF-L, tau protein, and GFAP levels longitudinally in AN patients undergoing weight restoration. Blood samples were obtained from 54 acutely underweight, predominantly adolescent female AN patients and 54 age-matched healthy control participants. AN patients were studied in the severely underweight state and again after short-term partial weight restoration. Group comparisons revealed higher levels of NF-L, tau protein, and GFAP in acutely underweight patients with AN compared to healthy control participants. Longitudinally, a decrease in NF-L and GFAP but not in tau protein levels was observed in AN patients upon short-term partial weight restoration. These results may be indicative of ongoing neuronal and astroglial injury during the underweight phase of AN. Normalization of NF-L and GFAP but not tau protein levels may indicate an only partial restoration of neuronal and astroglial integrity upon weight gain after initial AN-associated cell damage processes.

Case report of anorexia nervosa showing periventricular gliosis at autopsy

Anorexia nervosa (AN) is a serious eating disorder characterized by self-starvation and extreme weight loss. It has the highest mortality rate among all psychiatric disorders. Recent research indicates that malnutrition in AN patients induces various kinds of functional brain damage, but the pathophysiology of AN remains unclear. We report here the neuropathological findings of a 31-year-old Japanese woman. At age 24, she had a fear of gaining weight and reduced her dietary intake; she had extremely low body weight associated with overeating then self-induced vomiting. She was clinically diagnosed as having AN and was admitted to a psychiatric hospital with severe depression and suicidal thoughts. At age 31, she died despite intensive physical care and psychotherapy. Neuropathological examination revealed increased capillary blood vessels and slight fibrillary gliosis in the mammillary bodies, with similarities to Wernicke encephalopathy. The brainstem exhibited the characteristic features of central pontine myelinolysis, characterized by a sharply demarcated region of myelin pallor and relative sparing of axons. Senile changes, including neurofibrillary tangles/senile plaques, were not significant. Severe fibrillary gliosis was prominent around periventricular regions, including the caudate nucleus and nucleus accumbens, which are associated with cognition, emotion, and emotional behaviors via the dopaminergic pathways. These findings indicate that prolonged malnutrition in AN patients may induce brain damage, leading to dysfunction of the reward-related dopaminergic pathways. Furthermore, they represent the first pathological evidence that dysfunction of the cortico-limbic-striatal circuitry is involved in the pathophysiology of psychiatric symptoms in AN patients.

Thirty years after anorexia nervosa onset, serum neurofilament light chain protein concentration indicates neuronal injury

Little is known about the long-term consequences of anorexia nervosa (AN) in terms of possible brain neuronal injury. We aimed at investigating whether women with adolescent-onset AN exhibit increased serum levels of neurofilament light chain protein (NfL), a biomarker for neuronal injury, compared with matched controls at 30-year follow-up. Blood samples were collected from 34 women with adolescent-onset AN and 38 matched healthy comparison women (COMP), at a mean age of 44 years (range 38-48 years). NfL was measured in serum using the in-house single molecule array (Simoa) method. The individuals were asked whether they or their parents had been diagnosed with dementia. The Swedish National Patient Register was searched for diagnoses related to dementia. Serum NfL concentrations were significantly higher in the AN group (AN 27.7 pg/ml; COMP 19.0 pg/ml; p = 0.041). When individuals with medical/neurological disorders in the AN and COMP groups were excluded, there was a statistically non-significant trend towards higher concentrations in the AN group (AN 27.4 pg/ml; COMP 18.8 pg/ml; p = 0.060). None of the participants had been diagnosed with dementia. There was no significant correlation between serum NfL and AN duration (r = 0.15). There was a moderate negative correlation between the serum NfL concentration and the current BMI in the AN group (r = 0.44). This is the first time that serum NfL has been assessed in middle-aged women with a history of adolescent-onset AN. The results suggest that there might be increased axonal degeneration as a sequel of AN. Individuals remaining underweight had higher serum NfL concentrations than those with a normal/high BMI. Additional studies are needed to confirm increased serum NfL concentrations in individuals recovered from AN. There is a need for further study of axonal degeneration as a consequence of AN.

Anorexia induces a microglial associated pro-inflammatory environment and correlates with neurodegeneration in the prefrontal cortex of young female rats

Dehydration-Induced Anorexia (DIA) is a murine model that reproduces weight loss and avoidance of food, despite its availability. The prefrontal cortex (PFC) integrates sensory inputs and updates associative learning to promote (hunger) or inhibit (satiety) food-seeking behavior. In this study we tested if anorexia induces a pro-inflammatory environment associated with microglia in the medial prefrontal cortex (mPFC) and orbitofrontal cortex (OFC), specific subregions of the PFC involved in appetite. Our results showed that anorexia increased microglial density, promoted a de-ramified morphology and augmented the de-ramified/ramified ratio in the mPFC and OFC but not in the motor cortex. Anorexia also increased the expression of the pro-inflammatory cytokines TNF-α, IL-6 and IL-1β. This pro-inflammatory environment associated with microglia activation correlates with neuronal damage as revealed by Fluoro Jade C (FJC) and NeuN immunolabeling. We conclude that anorexia triggers a pro-inflammatory environment associated with microglia that correlates with neurodegeneration in the mPFC and OFC.

Reduced astrocyte density underlying brain volume reduction in activity-based anorexia rats

OBJECTIVES

Severe grey and white matter volume reductions were found in patients with anorexia nervosa (AN) that were linked to neuropsychological deficits while their underlying pathophysiology remains unclear. For the first time, we analysed the cellular basis of brain volume changes in an animal model (activity-based anorexia, ABA).

METHODS

Female rats had 24 h/day running wheel access and received reduced food intake until a 25% weight reduction was reached and maintained for 2 weeks.

RESULTS

In ABA rats, the volumes of the cerebral cortex and corpus callosum were significantly reduced compared to controls by 6% and 9%, respectively. The number of GFAP-positive astrocytes in these regions decreased by 39% and 23%, total astrocyte-covered area by 83% and 63%. In neurons no changes were observed. The findings were complemented by a 60% and 49% reduction in astrocyte (GFAP) mRNA expression.

CONCLUSIONS

Volumetric brain changes in ABA animals mirror those in human AN patients. These alterations are associated with a reduction of GFAP-positive astrocytes as well as GFAP expression. Reduced astrocyte functioning could help explain neuronal dysfunctions leading to symptoms of rigidity and impaired learning. Astrocyte loss could constitute a new research target for understanding and treating semi-starvation and AN.

Structural Neuroimaging of Anorexia Nervosa: Future Directions in the Quest for Mechanisms Underlying Dynamic Alterations

Anorexia nervosa (AN) is a serious eating disorder characterized by self-starvation and extreme weight loss. Pseudoatrophic brain changes are often readily visible in individual brain scans, and AN may be a valuable model disorder to study structural neuroplasticity. Structural magnetic resonance imaging studies have found reduced gray matter volume and cortical thinning in acutely underweight patients to normalize following successful treatment. However, some well-controlled studies have found regionally greater gray matter and persistence of structural alterations following long-term recovery. Findings from diffusion tensor imaging studies of white matter integrity and connectivity are also inconsistent. Furthermore, despite the severity of AN, the number of existing structural neuroimaging studies is still relatively low, and our knowledge of the underlying cellular and molecular mechanisms for macrostructural brain changes is rudimentary. We critically review the current state of structural neuroimaging in AN and discuss the potential neurobiological basis of structural brain alterations in the disorder, highlighting impediments to progress, recent developments, and promising future directions. In particular, we argue for the utility of more standardized data collection, adopting a connectomics approach to understanding brain network architecture, employing advanced magnetic resonance imaging methods that quantify biomarkers of brain tissue microstructure, integrating data from multiple imaging modalities, strategic longitudinal observation during weight restoration, and large-scale data pooling. Our overarching objective is to motivate carefully controlled research of brain structure in eating disorders, which will ultimately help predict therapeutic response and improve treatment.

Extend, Pathomechanism and Clinical Consequences of Brain Volume Changes in Anorexia Nervosa

INTRODUCTION

Brain volume deficits of grey matter (GM) and white matter (WM) are often found in patients with anorexia nervosa (AN). However, until recently, little was known about the influencing factors of these brain volume alterations, nor their exact quantification and rehabilitation.

METHODS

This review addresses these open questions and further explores what is now known about the underlying pathobiology and the clinical consequences including human studies as well as animal studies mimicking anorexia nervosa in rodents.

RESULTS

GM was reduced by 3.7% in adults and 7.6% in adolescents with AN. WM was reduced on average 2.2% in adult patients and 3.2% in adolescents. Most volume deficits in adults are reversible after long-term recovery; for adolescents, data are less clear. The main influencing factors for GM were absolute lowest weight at admission and illness duration. Cerebellar and WM reductions at admission predicted clinical outcome at one year follow-up. New studies found GABA receptor changes in GM and astrocyte loss in both GM and WM, as well as a possible role for oestrogen deficit. All three could partly explain clinical symptoms of anxiety, rigidity and learning impairments in patients with AN.

CONCLUSION

Brain volume deficits in AN seem to play a causal role in the course and the prognosis of AN. A better understanding of these brain changes could lead to more targeted therapies for patients with AN, including astrocyte-directed approaches.

Grey matter volume in adolescents with anorexia nervosa and associated eating disorder symptoms

Anorexia nervosa (AN) is a mental health disorder of complex aetiology. Previous neuroimaging studies have found consistent global reductions in global grey matter volume of underweight girls with AN; however, differences in regional grey matter volumes are less consistent. The aims of this study were to investigate grey matter regional volumes of adolescent girls with AN before and after weight recovery and the relationship of any changes with clinical characteristics. We collected high-resolution T1-weighted images from 26 underweight girls with AN before weight gain and 20 healthy control volunteers. Clinical features were assessed using the Eating Disorder Examination Questionnaire. AN subjects displayed reduced grey matter volumes in the insula, amygdala, prefrontal, hippocampal and cingulate cortices and the precuneus, relative to healthy controls. In a subset of 10 AN subjects who were followed after weight recovery, grey matter volumes increased to near-control levels in the orbito- and medial prefrontal, insular, left hippocampal and mid- and posterior cingulate cortices and precuneus. The recovery of the right anterior thalamus and the left orbitofrontal cortex was correlated with improvements in eating concerns and shape concerns, respectively. However, large parts of the anterior cingulate cortex, caudate nuclei and right hippocampus did not display any grey matter recovery following a short-term of treatment. These results show that in adolescents with AN, some brain regions display marked recovery in grey matter volume following weight recovery, whereas others do not, considering grey mater recovery possibly linked to symptom improvement.

The relationship between cortical thickness and body mass index differs between women with anorexia nervosa and healthy controls

Anorexia nervosa (AN) is a severe psychiatric disorder characterized by extreme underweight. Studies conducted with structural MRI found reductions in brain volumes in several areas, but results are mixed. Cortical thickness has shown in other samples specific correlations with BMI in different BMI ranges. In this study, we applied a well validated procedure implemented in Freesurfer software toolkit to investigate cortical thickness in a sample of 21 patients with AN and 18 healthy controls, focusing on group differences and on the relationship between BMI and cortical thickness. Cortical thickness was reduced in patients with AN, but group differences did not survive correction for multiple comparisons. The relationship between BMI and cortical thickness was significantly different in patients with AN compared to controls in the left superior parietal/occipital cortex and left post central cortex. These findings suggest that the relationship between cortical thickness and BMI in patients with AN with less than two years of illness duration significantly differs from that in controls and possible biological mechanisms that may explain this relationship are discussed.

Weight restoration therapy rapidly reverses cortical thinning in anorexia nervosa: A longitudinal study

Structural magnetic resonance imaging studies have documented reduced gray matter in acutely ill patients with anorexia nervosa to be at least partially reversible following weight restoration. However, few longitudinal studies exist and the underlying mechanisms of these structural changes are elusive. In particular, the relative speed and completeness of brain structure normalization during realimentation remain unknown. Here we report from a structural neuroimaging study including a sample of adolescent/young adult female patients with acute anorexia nervosa (n=47), long-term recovered patients (n=34), and healthy controls (n=75). The majority of acutely ill patients were scanned longitudinally (n=35): at the beginning of standardized weight restoration therapy and again after partial weight normalization (>10% body mass index increase). High-resolution structural images were processed and analyzed with the longitudinal stream of FreeSurfer software to test for changes in cortical thickness and volumes of select subcortical regions of interest. We found globally reduced cortical thickness in acutely ill patients to increase rapidly (0.06 mm/month) during brief weight restoration therapy (≈3 months). This significant increase was predicted by weight restoration alone and could not be ascribed to potentially mediating factors such as duration of illness, hydration status, or symptom improvements. By comparing cortical thickness in partially weight-restored patients with that measured in healthy controls, we confirmed that cortical thickness had normalized already at follow-up. This pattern of thinning in illness and rapid normalization during weight rehabilitation was largely mirrored in subcortical volumes. Together, our findings indicate that structural brain insults inflicted by starvation in anorexia nervosa may be reversed at a rate much faster than previously thought if interventions are successful before the disorder becomes chronic. This provides evidence drawing previously speculated mechanisms such as (de-)hydration and neurogenesis into question and suggests that neuronal and/or glial remodeling including changes in macromolecular content may underlie the gray matter alterations observed in anorexia nervosa.

Gyrification brain abnormalities as predictors of outcome in anorexia nervosa

Gyrification brain abnormalities are considered a marker of early deviations from normal developmental trajectories and a putative predictor of poor outcome in psychiatric disorders. The aim of this study was to explore cortical folding morphology in patients with anorexia nervosa (AN). A MRI brain study was conducted on 38 patients with AN, 20 fully recovered patients, and 38 healthy women. Local gyrification was measured with procedures implemented in FreeSurfer. Vertex-wise comparisons were carried out to compare: (1) AN patients and healthy women; (2) patients with a full remission at a 3-year longitudinal follow-up assessment and patients who did not recover. AN patients exhibited significantly lower gyrification when compared with healthy controls. Patients with a poor 3-year outcome had significantly lower baseline gyrification when compared to both healthy women and patients with full recovery at follow-up, even after controlling for the effects of duration of illness and gray matter volume. No significant correlation has been found between gyrification, body mass index, amount of weight loss, onset age, and duration of illness. Brain gyrification significantly predicted outcome at follow-up even after controlling for the effects of duration of illness and other clinical prognostic factors. Although the role of starvation in determining our findings cannot be excluded, our study showed that brain gyrification might be a predictor of outcome in AN. Further studies are needed to understand if brain gyrification abnormalities are indices of early neurodevelopmental alterations, the consequence of starvation, or the interaction between both factors.

Brain volume reduction predicts weight development in adolescent patients with anorexia nervosa

BACKGROUND

Acute anorexia nervosa (AN) is associated with marked brain volume loss potentially leading to neuropsychological deficits. However, the mechanisms leading to this brain volume loss and its influencing factors are poorly understood and the clinical relevance of these brain alterations for the outcome of these AN-patients is yet unknown.

METHODS

Brain volumes of 56 female adolescent AN inpatients and 50 healthy controls (HCs) were measured using MRI scans. Multiple linear regression analyses were used to determine the impact of body weight at admission, prior weight loss, age of onset and illness duration on volume loss at admission and to analyse the association of brain volume reduction with body weight at a 1-year follow-up (N = 25).

RESULTS

Cortical and subcortical grey matter (GM) and cortical white matter (WM) but not cerebellar GM or WM were associated with low weight at admission. Amount of weight loss, age of onset and illness duration did not independently correlate with any volume changes. Prediction of age-adjusted standardized body mass index (BMI-SDS) at 1-year follow-up could be significantly improved from 34% of variance explained by age and BMI-SDS at admission to 47.5-53% after adding cortical WM, cerebellar GM or WM at time of admission.

CONCLUSION

Whereas cortical GM changes appear to be an unspecific reflection of current body weight ("state marker"), cortical WM and cerebellar volume losses seem to indicate a longer-term risk (trait or "scar" of the illness), which appear to be important for the prediction of weight rehabilitation and long-term outcome.

Global cortical thinning in acute anorexia nervosa normalizes following long-term weight restoration

BACKGROUND

Anorexia nervosa (AN) is a serious eating disorder characterized by self-starvation, extreme weight loss, and alterations in brain structure. Structural magnetic resonance imaging studies have documented brain volume reductions in acute AN, but it is unclear whether they are 1) regionally specific, or 2) reversible following weight restoration. Here, we measured cortical thickness (CT) for the first time in AN.

METHODS

Structural magnetic resonance imaging data were acquired from adolescent and young adult female patients with acute AN (n = 40), recovered patients following long-term weight restoration (n = 34), and an equal number of age-matched healthy control subjects. Group differences in CT were tested with well-validated procedures implemented in FreeSurfer. The mediating role of clinical variables including body mass index and drive for thinness were explored. For completeness, we also used FreeSurfer's subcortical segmentation stream to test group differences in volumes of select gray matter regions of interest.

RESULTS

Vertex-wise analyses revealed significant thinning of over 85% of the cortical surface in patients with acute AN and CT normalization in recovered patients following long-term weight restoration, although normal age-related trajectories were absent in the disorder. This pattern of results was largely mirrored in subcortical volumes. We also observed a strong negative correlation between CT and drive for thinness in extrastriate regions involved in body perception.

CONCLUSIONS

Structural brain anomalies in AN as expressed in CT and subcortical volume are primarily the consequence of malnutrition and unlikely to reflect premorbid trait markers or permanent scars, but longitudinal data are needed.

Morphological Changes in the Brain of Acutely Ill and Weight-Recovered Patients with Anorexia Nervosa

Objective: Acute anorexia nervosa (AN) leads to reduced gray (GM) and white matter (WM) volume in the brain, which however improves again upon restoration of weight. Yet little is known about the extent and clinical correlates of these brain changes, nor do we know much about the time-course and completeness of their recovery. Methods: We conducted a meta-analysis and a qualitative review of all magnetic resonance imaging studies involving volume analyses of the brain in both acute and recovered AN. Results: We identified structural neuroimaging studies with a total of 214 acute AN patients and 177 weight-recovered AN patients. In acute AN, GM was reduced by 5.6% and WM by 3.8% compared to healthy controls (HC). Short-term weight recovery 2–5 months after admission resulted in restitution of about half of the GM aberrations and almost full WM recovery. After 2–8 years of remission GM and WM were nearly normalized, and differences to HC (GM: –1.0%, WM: –0.7%) were no longer significant, although small residual changes could not be ruled out. In the qualitative review some studies found GM volume loss to be associated with cognitive deficits and clinical prognosis. Conclusions: GM and WM were strongly reduced in acute AN. The completeness of brain volume rehabilitation remained equivocal.

Sudden death in eating disorders

Eating disorders are usually associated with an increased risk of premature death with a wide range of rates and causes of mortality. “Sudden death” has been defined as the abrupt and unexpected occurrence of fatality for which no satisfactory explanation of the cause can be ascertained. In many cases of sudden death, autopsies do not clarify the main cause. Cardiovascular complications are usually involved in these deaths. The purpose of this review was to report an update of the existing literature data on the main findings with respect to sudden death in eating disorders by means of a search conducted in PubMed. The most relevant conclusion of this review seems to be that the main causes of sudden death in eating disorders are those related to cardiovascular complications. The predictive value of the increased QT interval dispersion as a marker of sudden acute ventricular arrhythmia and death has been demonstrated. Eating disorder patients with severe cardiovascular symptoms should be hospitalized. In general, with respect to sudden death in eating disorders, some findings (eg, long-term eating disorders, chronic hypokalemia, chronically low plasma albumin, and QT intervals >600 milliseconds) must be taken into account, and it must be highlighted that during refeeding, the adverse effects of hypophosphatemia include cardiac failure. Monitoring vital signs and performing electrocardiograms and serial measurements of plasma potassium are relevant during the treatment of eating disorder patients.

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.

Implications of starvation-induced change in right dorsal anterior cingulate volume in anorexia nervosa

OBJECTIVE

Converging evidence suggests a role for the anterior cingulate cortex (ACC) in the pathophysiology of anorexia nervosa (AN). This study sought to determine whether ACC volume was affected by starvation in active AN and, if so, whether this had any clinical significance.

METHOD

Eighteen patients with active AN and age- and gender-matched normal controls underwent magnetic resonance imaging (MRI). Sixteen patients (89%) with AN had intelligence quotients (IQ) testing at intake, 14 (78%) had repeat MRIs after weight normalization, and 10 (56%) had outcome data at 1-year posthospitalization.

RESULTS

Right dorsal ACC volume was significantly reduced in active AN patients versus controls and was correlated with lower performance IQ. While ACC normalization occurred with weight restoration, smaller change in right dorsal ACC volume prospectively predicted relapse after treatment.

CONCLUSION

Reduced right dorsal ACC volume during active AN relates to deficits in perceptual organization and conceptual reasoning. The degree of right dorsal ACC normalization during treatment is related to outcome.

Classification Matters for Catatonia and Autism in Children

Despite its chequered history, Kahlbaum's 1874 description of catatonia (tension insanity) and its categorization as a clinical illness is in outline still valid. Kahlbaum also acknowledged the existence of catatonia in children. Corresponding case studies have also been analyzed. The originators and disciples of the Wernicke-Kleist-Leonhard school proved catatonia in early childhood as a discrete entity with specific psychopathology. This does not mean that catatonic symptoms do not occur in other illnesses and in particular in organic psychoses. These are, however, of a totally different nature. Autism, as first described in connection with schizophrenic negativism by Bleuler in 1910, is one of the key symptoms of schizophrenia. As identified by Kanner in 1943, abnormal social interaction and communication, together with retarded development, are the main characteristics of autism in early childhood. Asperger's concept of autistic disorder (1944), although based on psychopathological theory, did not include retardation in development as an aspect. Consequently, autistic behavior can occur in a variety of mental disorders. Research into possible etiological and pathogenetic factors has been undertaken, but no clear link found as yet.

Are there specific disabilities of number processing in adolescent patients with Anorexia nervosa? Evidence from clinical and neuropsychological data when compared to morphometric measures from magnetic resonance imaging

The cerebral effect of the loss of body weight in Anorexia nervosa (A.n.)--the so-called 'pseudoatrophy'-- is well known and confirmed by several neuroimaging studies. Another subject of intensive research has been whether A.n. leads to specific cognitive impairments, especially of intelligence. However, there are no previous studies on the relations between the cerebral changes, intelligence performance, and disorders of number processing in adolescent patients with A.n. We examined n = 18 inpatients with A.n. (means at admission: age 14.5 years, SD 1.59; BMI 14.9, SD 1.36), diagnosed according to ICD-10 criteria at three different timepoints: at admission to treatment (T1), with 50 % restoration of their normal weight (T2), and with normal weight (T3). At each timepoint, a cerebral MRI scan was obtained. Based on the MRI we determined the volume of the external and internal cerebrospinal fluid cavities, fissures of Sylvius, the surface of mesencephalon and pons, and surface and length of the Corpus callosum. At T1 and T3, a neuropsychological examination was conducted including tests of the general fluid ability and general cristallized ability of intelligence (CFT-20), as well as tests of vocabulary and number processing. The same instruments were given to a group of matched controls (means: age 15.8 years, SD 1.57; BMI 20.5, SD 2.3) at one timepoint. We could show a significant volume difference of the lateral ventricles and the fissure of Sylvius between patients at T, and controls, which abaded with the patient's weight restoration. But a significant surface deficit of the mesencephalon, and less pronounced in the pons, persisted to T3 in patients when compared to controls, suggesting a selectivity of the cerebral changes in A.n. The neuropsychological examinations revealed significant changes in test performance for both the general intelligence test and number processing. At T1 the number processing performance was significantly lower in patients when compared to controls. However, when the patients had restored their normal body weight, we found 2.02 % with a 'severe disorder of arithmetic skills' and 4.45 % with a 'functional disorder of arithmetic skills'. This combined prevalence of 6.47 % of patients with a subnormal arithmetic performance is analogous to that in the normal population.

Anorexia nervosa - Die Trias von Metrik-Index, BMI-Altersperzentilenkurve und Zielgewicht

Zusammenfassung: Anhand von n = 133 adoleszenten Patientinnen der Berliner Anorexie-Studie belegen Quer- und Längsschnittdaten der stationären Therapie bei Anorexia nervosa (n = 104; Achse-I-Hauptdiagnose nach ICD-10 und DSM-IV-Kriterien), Bulimia nervosa (n = 19) und atypischen Eßstörungen (n = 10) eine signifikante Verschiebung der nach dem Metrik-Index kategorisierten typologischen Häufigkeitsverteilung in Richtung leptomorpher Körperbauvarianten (p < 0.050, χ2/Fisher's). Drei Erklärungsmodelle werden diskutiert. Es wird auf die diagnostische und therapeutische Bedeutung eingegangen, insbesondere für eine körperbautypgerechte Zielgewichtsbestimmung bei Anorexia nervosa. Ein entsprechender Algorithmus unter Nutzung von Metrix-Index und geschlechtsspezifischen BMI-Altersperzentilen wird vorgeschlagen.