Family history of anxiety and mood disorders in anorexia nervosa: review of the literature

[Depressive symptoms during anorexia nervosa: State of the art and consequences for an appropriate use of antidepressants]

OBJECTIVE

Depressive comorbidity is often associated with anorexia nervosa (AN), and antidepressant medication is widely used although it does not rely on any convincing data in the scientific literature. Our objectives were: to summarize the epidemiological, physiological, psychopathological literature about the relation between AN and manifestations of depression, and to focus on the clinical trial data assessing the use of antidepressant medication in AN in order to clarify the strategy for the use of antidepressant in AN during adolescence.

METHOD

A manual computerised search (Medline) was performed for relevant published studies assessing the association between depressive signs or Major Depressive Disorder (MDD) and AN. Another manual computerised search (Medline) listed clinical trials assessing antidepressant in AN.

RESULTS

On the one hand, depressive symptoms are common during the course of AN and could have different meaning. Indeed, firstly, we can distinguish symptoms that are inherent to AN and which can be mistaken for depressive signs (for instance: low self-esteem, reduced social contacts). Secondly, long-term undernourishment can be held responsible for numerous psychological distortions, including anxiety and depression symptoms such as insomnia, impaired concentration, or social isolation. Thirdly, the natural course of AN can also lead to "depressive moments", in particular when switching to a "purging type" AN, or when recovery mobilizes control and narcissistic issues. On the other hand, MDD is also highly prevalent among AN patients and is a negative prognosis factor. Thus, it is complex to differentiate MDD from isolated depressive symptoms that could be inherent of the AN symptomatology which raises the question of the role of antidepressant medication in treatment of depression in AN. No significant benefit of antidepressant medication in AN has been shown in clinical trials, and according to international guidelines it should be prescribed only as a second-line treatment, after appropriate refeeding, and in case of an authentic depressive disorder. Those data appear to be in contradiction with the frequent use of those drugs in clinical practice.

DISCUSSION

Nevertheless, clinical trials assessing antidepressant treatment in AN suffer from methodological weakness concerning the size of the sample, the choice of the population or the evaluation criterion. This lack of proof must raise our vigilance concerning antidepressant medication in AN but should not categorically prevent the clinician from using it when necessary. We do believe that there are some indications for prescribing antidepressant in patients with AN. The clinical challenge lies in the differentiation of the depressive symptoms that are transitory and likely to improve without medication from those that signal the presence of an MDD. Three criterion could be indicative of MDD: familial history of mood disorder, as it is a major risk factor for MDD among relatives; the chronology of appearance of both disorders, when MDD pre-exists AN; a few specific symptoms cannot be attributed to undernourishment or reactive depressive signs, such as morning insomnia, daily variation of depressive symptoms, suicidal attempts or ideation and guilt ideation. Thus, in integrating the data from the literature review, we propose a pragmatic therapeutic strategy for the use of an antidepressant in AN during adolescence that lies in 3 main categories for depressive manifestations in AN: therapeutic emergencies: when an obvious and severe MDD is comorbid to AN, immediate antidepressant would be required; isolated and non-specific depressive sign: no medication would be relevant as they are supposed to improve with refeeding and psychotherapeutic support; intermediary patterns which is probably the most frequent situation. In the last case, it would be relevant to abstain from prescribing medication in first line, but an antidepressant medication should be quickly considered in the presence of one (or several) criterion listed above and its persistence despite refeeding. The general medical state of this fragile population of patients should be evaluated (standard blood test, ECG) before and during treatment.

Enlargement of Axo-Somatic Contacts Formed by GAD-Immunoreactive Axon Terminals onto Layer V Pyramidal Neurons in the Medial Prefrontal Cortex of Adolescent Female Mice Is Associated with Suppression of Food Restriction-Evoked Hyperactivity and Resilience to Activity-Based Anorexia

Many, but not all, adolescent female mice that are exposed to a running wheel while food restricted (FR) become excessive wheel runners, choosing to run even during the hours of food availability, to the point of death. This phenomenon is called activity-based anorexia (ABA). We used electron microscopic immunocytochemistry to ask whether individual differences in ABA resilience may correlate with the lengths of axo-somatic contacts made by GABAergic axon terminals onto layer 5 pyramidal neurons (L5P) in the prefrontal cortex. Contact lengths were, on average, 40% greater for the ABA-induced mice, relative to controls. Correspondingly, the proportion of L5P perikaryal plasma membrane contacted by GABAergic terminals was 45% greater for the ABA mice. Contact lengths in the anterior cingulate cortex correlated negatively and strongly with the overall wheel activity after FR (R = -0.87, P < 0.01), whereas those in the prelimbic cortex correlated negatively with wheel running specifically during the hours of food availability of the FR days (R = -0.84, P < 0.05). These negative correlations support the idea that increases in the glutamic acid decarboxylase (GAD) terminal contact lengths onto L5P contribute toward ABA resilience through suppression of wheel running, a behavior that is intrinsically rewarding and helpful for foraging but maladaptive within a cage.

Association between a common CYP17A1 haplotype and anxiety in female anorexia nervosa

Dehydroepiandrosterone (DHEA), the main brain neurosteroid, has been implicated in various psychiatric disorders especially those including gender differences. We studied genetic variability in the DHEA-producing enzyme CYP17A1 in relation to anorexia nervosa (AN) susceptibility and AN-related co-morbidities. We performed analysis of 100 Israeli AN family trios accounting for CYP17A1 haplotypes characteristic of populations of European origin and studied genotype-phenotype relationships using correlation analyses and transmission disequilibrium test. Although our analysis revealed no evidence of association between CYP17A1 and AN per se, it revealed an association between specific CYP17A1 haplotypes and AN co-morbidity, specifically anxiety. We found that a common CYP17A1 haplotype (H1) was associated with higher anxiety in AN patients (Clinical Global Impression; CGI-anxiety ≥4). Moreover, H1 homozygotes were at higher risk for expressing high CGI-anxiety levels (OR = 3.7), and H1 was preferentially transmitted to AN patients with high CGI-anxiety levels (P = 0. 037). We suggest that CYP17A1 H1 haplotype may contribute to genetic predisposition to higher CGI-anxiety levels in AN patients and that this predisposition may be mediated by reduced CYP17A1 enzymatic activity and corresponding lower DHEA production.

Relationship between malnutrition and depression or anxiety in Anorexia Nervosa: a critical review of the literature

BACKGROUND

Depression, anxiety and obsessive-compulsive disorder (OCD) frequently co-occur with Anorexia Nervosa (AN). Clinical consensus admits that depressive symptoms and anxiety are the sequelae of malnutrition in AN. This review presents a critical assessment of the literature that looked into the link between depression/anxiety symptoms in relation to malnutrition and their improvement throughout the treatment.

METHODS

We performed a systematic search of literature in Medline and PsychInfo for all the studies done to investigate psychological factors in relation to malnutrition in AN using the keywords "Anorexia Nervosa", "depression", "anxiety", "obsessive-compulsive disorder" and "malnutrition". Only articles published between 1980 and 2010 in English or French were reviewed. From the articles on AN and depression, anxiety, and/or OCD, only the ones which investigated on the relation with malnutrition were kept. This search was complemented by a manual search. We also checked the reference lists of the articles we found.

RESULTS

Seven papers were analyzed and critically reviewed for their methods and results. Results are contradictory and inconsistent at all levels of assessment.

CONCLUSIONS

Evidence based data is very rare. From the 7 reviewed studies, none of them draw the same conclusion. This is mainly due to the large differences in the samples' populations and the studies' protocols. Future studies are needed to focus on the relationship between depression/anxiety symptoms and malnutrition. A more critical nutritional assessment should be undertaken with multiple psychological assessment scales.

The relationship of bulimia and anorexia nervosa with bipolar disorder and its temperamental foundations

BACKGROUND

Earlier studies have suggested a relationship between bipolar disorder (BP) and eating disorders (ED), more specifically, bulimia nervosa (BN) and bipolar II disorder (BP-II). In the present report we extend this relationship to broader definitions of bipolarity.

METHODS

Semi-structured interview of 201 patients with DSM-IV criteria for major affective disorders combined with Akiskal and Mallya criteria for Affective temperaments. To diagnose lifetime comorbid eating disorders DSM-IV criteria for eating disorders (Bulimia Nervosa, BN, Anorexia, AN) were used.

RESULTS

33 patients had an eating disorder. When compared to patients without ED the patients with ED had a higher prevalence of bipolar disorders. Using strict DSM-IV criteria, this association was only significant for BN (OR) 4.5 (95% CI 1.1-17.6). When using a broader index of bipolarity including patients having affective temperaments, a significant relation was found for BN (OR) 9.1 (95% CI 1.1-73.6), and for patients with a lifetime history of both BN and AN (OR) 8.6 (95% CI 1.1-70.2).We also found patients with ED to have a significantly higher prevalence of affective temperaments, an earlier onset of major affective disorder and to have more depressive episodes.

LIMITATIONS

Non-blind evaluation of diagnosis for mood, eating disorders and affective temperaments.

CONCLUSION

In line with previous reports we describe an association between bulimia nervosa and bipolar disorder. Furthermore we report a relationship between lifetime bulimia and anorexia and cyclothymic and related affective temperaments.

Adolescent eating disorders: definitions, symptomatology, epidemiology and comorbidity

Eating disorders have morbidity and mortality rates that are among the highest of any mental disorders and are associated with significant functional impairment. This article provides an up-to-date review on recent developments and expanding knowledge in adolescent anorexia nervosa, bulimia nervosa, and related disorders. It covers diagnoses and assessment, recognition of typical symptoms, medical and psychiatric comorbidities, and current trends in epidemiology.