Anorexia nervosa with excessive exercise: a phenotype with close links to obsessive-compulsive disorder

Adaptive and Maladaptive Exercise in Eating Disorders

While exercise is generally associated with positive health outcomes, in the context of eating disorders, exercise has high potential to become maladaptive. Maladaptive exercise is compelled or compulsive in nature for the purposes of weight and shape control or to obtain/avoid other eating disorder-relevant consequences. A transdiagnostic eating disorder feature with moderate-to-high prevalence across restrictive- and bulimic-spectrum eating disorders, maladaptive exercise is often associated with negative mental and physical health sequalae. Several proposed threat- and reward-related biobehavioral mechanisms may initiate or perpetuate maladaptive exercise. While exercise is generally contraindicated during periods of acute medical concern, adaptive forms of exercise are also present among those with eating disorders, and facilitation of adaptive exercise has potential to promote physical and mental health benefits during eating disorder recovery. Detailed assessment and targeted interventions are needed to address the clinical conundrum of how and when to integrate exercise into eating disorder treatment.

Assessment and treatment of compulsive exercise in anorexia nervosa - A combined investigation of Compulsive Exercise Activity Therapy (LEAP) and Compulsive Exercise Test subscales

INTRODUCTION

Compulsive exercise is a transdiagnostic feature of eating disorders which adversely affects aspects of recovery, such as length of hospitalisation, risk of a chronic outcome, and risk of relapse. CompuLsive Exercise Activity TheraPy (LEAP) aims to reduce compulsive exercise through a cognitive behavioural approach. This study aims to investigate the effect of LEAP on compulsive exercise behaviour using subscales of the Compulsive Exercise Test (CET), a measure of exercise in individuals with eating disorders. Predictive validity of the CET's subscales and its ability to predict eating psychopathology are investigated.

METHOD

This study used data from a randomized controlled trial of LEAP (1). Linear mixed modelling was used to investigate the effect of LEAP on compulsive exercise behaviour, and the predictive ability of CET subscales on various outcomes. The CET was compared to other exercise measures to assess its superiority in predicting eating psychopathology.

RESULTS

LEAP was superior in reducing the scores of the CET's Avoidance and Rule Driven Behaviour and Exercise Rigidity subscales. All subscales made a contribution to the respective models. The CET was superior to other measures in predicting eating pathology.

CONCLUSION

The results lend credibility to LEAP's ability to reduce core parts of compulsive exercise. The CET has been found to target important aspects of compulsive exercise behaviour, and has was superior to other exercise measures in predicting eating psychopathology.

Classifying excessive exercise: Examining the relationship between compulsive exercise with obsessive-compulsive disorder symptoms and disordered eating symptoms

OBJECTIVE

There remains a lack of consensus around nosology for compulsive exercise (CE). Although widely observed in eating disorders (ED), CE shares theoretical overlap with obsessive-compulsive disorder (OCD), where exercise compulsions occur in response to obsessions. Yet, there is limited and mixed evidence of a relationship between CE with OCD. This study aims to explore the appropriate diagnostic classification of CE through examination of CE in relation to OCD, obsessional thinking, and ED symptoms.

METHOD

Two hundred and eighty one adults with mental health symptoms, dieting, and exercise behaviour completed measures of OCD, CE, and disordered eating symptoms. Regression and Receiver Operating Characteristic analyses examined relationships between dimensions of CE with OCD and ED symptoms, and the predictive ability of CE assessment for detecting threshold OCD and ED symptoms.

RESULTS

CE assessment was poor at predicting threshold OCD symptoms, probable Anorexia Nervosa, and Binge Eating Disorder and moderate at detecting probable disordered eating and Bulimia Nervosa. Associations between CE and OCD symptoms were not significant after adjustment for ED symptoms. Obsessional thinking was associated only with lack of exercise enjoyment.

CONCLUSIONS

Results indicate that excessive exercise might represent a distinct disorder, with some shared traits across CE, OCD and ED symptoms. Findings question the utility of adaptation of OCD diagnostic criteria for CE. Assessment and treatment implications are considered.

Predicting eating disorder and anxiety symptoms using disorder-specific and transdiagnostic polygenic scores for anorexia nervosa and obsessive-compulsive disorder

BACKGROUND

Clinical, epidemiological, and genetic findings support an overlap between eating disorders, obsessive-compulsive disorder (OCD), and anxiety symptoms. However, little research has examined the role of genetics in the expression of underlying phenotypes. We investigated whether the anorexia nervosa (AN), OCD, or AN/OCD transdiagnostic polygenic scores (PGS) predict eating disorder, OCD, and anxiety symptoms in a large developmental cohort in a sex-specific manner.

METHODS

Using summary statistics from Psychiatric Genomics Consortium AN and OCD genome-wide association studies, we conducted an AN/OCD transdiagnostic genome-wide association meta-analysis. We then calculated AN, OCD, and AN/OCD PGS in participants from the Avon Longitudinal Study of Parents and Children to predict eating disorder, OCD, and anxiety symptoms, stratified by sex (combined N = 3212-5369 per phenotype).

RESULTS

The PGS prediction of eating disorder, OCD, and anxiety phenotypes differed between sexes, although effect sizes were small. AN and AN/OCD PGS played a more prominent role in predicting eating disorder and anxiety risk than OCD PGS, especially in girls. AN/OCD PGS provided a small boost over AN PGS in the prediction of some anxiety symptoms. All three PGS predicted higher compulsive exercise across different developmental timepoints [β = 0.03 (s.e. = 0.01) for AN and AN/OCD PGS at age 14; β = 0.05 (s.e. = 0.02) for OCD PGS at age 16] in girls.

CONCLUSIONS

Compulsive exercise may have a transdiagnostic genetic etiology, and AN genetic risk may play a role in the presence of anxiety symptoms. Converging with prior twin literature, our results also suggest that some of the contribution of genetic risk may be sex-specific.

Relationships between personality traits and disordered eating among Chinese female exercisers: the role of symptoms of exercise dependence and obsessive-compulsiveness

BACKGROUND

Although numerous studies have examined associations between personality traits and eating disorders in females, few studies have been conducted on female exercisers. Given the high risk of disordered eating in female exercisers, this study investigated the associations between the Big Five personality traits and disordered eating in female exercisers, and further explored the potential mediators, namely exercise dependence symptoms, and obsessive-compulsive symptoms underlying this association.

METHODS

A total of 295 female exercisers aged between 18 to 67 years (M =  22.11, SD =  6.65) participated in this study.

RESULTS

Negative and statistically significant correlations between conscientiousness (r = - 0.17, p < 0.01), emotional stability (r = - 0.27, p < 0.001) and agreeableness (r = - 0.18, p < 0.01) and disordered eating were observed in our sample of female exercisers. The multiple mediation analyses revealed that exercise dependence symptoms and obsessive-compulsive symptoms mediate the relationship between conscientiousness (β = 0.016, CI = [0.003, 0.031]), emotional stability (β = -0.012, CI = [- 0.028, - 0.002]), and disordered eating in female exercisers, whereas obsessive-compulsive symptoms (β = - 0.041, CI = [- 0.088, - 0.001]) but not exercise dependence symptoms are a mediator of the relationship between agreeableness and disordered eating.

CONCLUSIONS

Our findings can be used to improve the screening procedures for eating disorders in female exercisers as they contribute to a better understanding of the psychological mechanisms that underlie the associations between the Big Five personality traits and disordered eating.

Increased Habit Frequency in the Daily Lives of Patients with Acute Anorexia Nervosa

Strict eating routines and frequent rigid behavior patterns are commonly observed in patients with anorexia nervosa (AN). A recent theory proposes that while these behaviors may have been reinforced initially, they later become habitual. To date, however, research has been overly focused on eating-disorder (ED)-related habits. Over the course of seven days, we applied an ecological momentary assessment (EMA) to investigate the habit frequency and strength of ED-specific (food intake) and ED-unspecific (hygiene) habits in the daily lives of a sample of n = 57 AN and n = 57 healthy controls (HC). The results of the hierarchical models revealed that habits were significantly more likely in patients compared with HC for both categories, independently. Furthermore, a lower body mass index (BMI) was associated with increased habit frequency in AN. Our study strengthens the habit theory of AN by showing the relevance of habits beyond ED-specific behavioral domains. This also supports the development of innovative therapeutic interventions targeting habitual behavior in EDs.

Measuring exercise in eating disorder patients: a Delphi study to aggregate clinical and research knowledge

BACKGROUND

Exercise is a prominent feature of most eating disorders, and has been shown to have a number of detrimental effects on treatment outcome. There is some disagreement in the literature regarding the construct of compulsive exercise, and assessment and treatment varies significantly. This study therefore aimed to aggregate expert clinicians' and researchers' views on how to define and measure compulsive exercise in eating disorder patients. The expert panel was also asked about questionnaire design, and possible problems when measuring compulsive exercise.

METHOD

This study used the Delphi method to establish consensus amongst an expert panel. Three successive rounds of questionnaires were distributed to the panel over a period of six months. The first round consisted of four open-ended questions regarding the definition and measurement of compulsive exercise in eating disorder patients. For Round 2, 70 statements were derived from the answers, and panelists were asked to rate each item on a Likert-based scale. An 85% consensus level was chosen. In Round 3, 44 statements were re-rated by the panel.

RESULTS

Seventeen of 24 participants completed all three rounds of the study. Consensus was achieved for 63% of the items, while 18.5% reached near consensus, and 18.5% did not reach consensus after Round 3. The panel agreed on a number of important aspects of compulsive exercise. Several suggestions regarding the format of a questionnaire assessing this behavior were also endorsed. The panel further identified common difficulties when assessing compulsive exercise in eating disorder patients, notably a lack of consensus still apparent in the literature.

CONCLUSION

The current findings constitute a further step towards a unified definition of compulsive exercise, and contribute important suggestions to the measurement of this behavior.

Restlessness and an Increased Urge to Move (Drive for Activity) in Anorexia Nervosa May Strengthen Personal Motivation to Maintain Caloric Restriction and May Augment Body Awareness and Proprioception: A Lesson From Leptin Administration in Anorexia Nervosa

Anorexia nervosa (AN), a disorder of voluntary food restriction leading to severe weight loss in female adolescents, remains an enigma. In particular, the appropriation of the starved thin body into the self-concept in AN is a process insufficiently researched and still poorly understood. Healthy humans undergoing starvation experience a slowing of movements and avoid voluntary exercise. By contrast, AN tends to be not infrequently associated with voluntary, sometimes excessive and/or compulsive exercise. Such deliberate exercise, not reported in starvation, seems to be facilitated by an increased urge for movement and physical restlessness, particular to AN. The increased urge to move would reflect spontaneous daily activity, the energy expended for everything that is not sleeping, eating, or voluntary exercise. Our hypothesis is that the starvation-induced increased urge to move and restlessness may promote the development of AN. Reversal of the fasting state, by either high caloric food or by leptin administration, would be expected to reduce restlessness and the increased urge to move along with improvement in other symptoms in AN. This review explores the idea that such restless activation in AN, in itself and through accelerating body weight loss, might foster the integration of the starving body into the self-concept by (1) enhancing the person’s sense of self-control and sense of achievement and (2) through invigorating proprioception and through intensifying the perception of the changing body shape. (3) Tentative evidence from studies piloting leptin administration in chronic AN patients which support this hypothesis is reviewed. The findings show that short term administration of high doses of leptin indeed mitigated depressive feelings, inner tension, intrusive thoughts of food, and the increased urge to be physically active, easing the way to recovery, yet had little influence on the patients’ personal commitment to remain at a low weight. Full recovery then requires resolution of the individuals’ personal unresolved psychological conflicts through psychotherapy and frequently needs specialized treatment approaches to address psychiatric co-morbidities. AN might be conceptualized as a hereditary form of starvation resistance, facilitated by the effects of starvation on fitness allowing for an exceptionally intense personal commitment to perpetuate food restriction.

Behavioral reinforcement of pathological exercise in anorexia nervosa

Pathological exercise in anorexia nervosa (AN) is a harmful behavior associated with a chronic course and poor prognosis. To date, no comprehensive theoretical model exists to describe pathological exercise in the context of AN, and as such, few treatments are effective at promoting direct and sustained pathological exercise extinction. Using a framework put forth by Wise & Koob (2014), debating the relative importance of positive and negative reinforcement in substance use, we present three hypotheses of behavioral reinforcement of exercise, encompassing biological, psychological, and environmental influences. Specifically, we argue that exercise is positively reinforced through receipt of biological and behavioral rewards, negatively reinforced through avoidance of aversive emotions, and that these two systems work in tandem over time to engrain pathological exercise as a habit. We then present suggestions for testing each of these hypotheses as future directions for the field.

High levels of physical activity in female adolescents with anorexia nervosa: medical and psychopathological correlates

PURPOSE

While overexercise is commonly described in patients who experience anorexia nervosa (AN), it represents a condition still underestimated, especially in the paediatric population.

METHOD

The present study aims at assessing the possible associations between levels of physical activity (PA) and clinical features, endocrinological data and psychopathological traits in a sample of 244 female adolescents hospitalised for AN subdivided into two groups according to PA levels (high PA vs. no/low PA). The two groups were compared through multivariate analyses, while multiple regression analysis was conducted to determine whether physical activity predict specific outcomes.

RESULTS

No significant differences were found between the two groups in terms of last Body Mass Index (BMI) before illness, BMI at admission and disease duration, while a difference emerged in delta BMI(rapidity of weight loss), significantly higher in high-PA group (p = 0.021). Significant differences were observed in Free triiodothyronine- (p < 0.001), Free thyroxine (p = 0.046), Follicle-stimulating hormone (p = 0.019), Luteinising hormone (p = 0.002) levels, with values remarkably lower in high-PA group. Concerning psychopathological scales, the high-PA group showed worst Children's Global Assessment Scale (CGAS) scores (p = 0.035). Regression analyses revealed that higher PA predicts higher delta BMI (p = 0.021), presence of amenorrhea (p = 0.003), lower heart rate (p = 0.012), lower thyroid (Free triiodothyronine p < 0.001, Free thyroxine p = 0.029) and gynaecological hormones' levels (Follicle-stimulating hormone p = 0.023, Luteinising hormone p = 0.003, 17-Beta estradiol p = 0.041). Concerning psychiatric measures, HPA predicts worst scores at CGAS (p = 0.019), and at scales for evaluation of alexithymia (p = 0.028) and depression (p = 0.004).

CONCLUSIONS

Results suggest that high levels of physical activity in acute AN associate with worst clinical conditions at admission, especially in terms of endocrinological and medical features.

LEVEL OF EVIDENCE

Level III.

Exercise therapy in the treatment of anorexia nervosa: Its effects depending on the type of physical exercise-A systematic review

BACKGROUND AND PURPOSE

Clinical research focusing on the effectiveness of exercise therapy (ET) in patients with anorexia nervosa (AN) shows increasing interest in the last decade. The aim of this systematic review was to provide an overview of quantitative studies that have examined the impact of ET in AN patients and to examine its specific effects on physical and mental health according to the type of physical exercise (PE) practiced.

METHODS

The review was carried out based on the PRISMA 2020. Electronic databases PubMed, Web of Science, Embase, and Wiley were searched from inception to December 2021. Quantitative studies assessing the effects of ET interventions on AN patients were included and study quality was assessed using the PEDro scale.

RESULTS

A total of 27 studies were selected, including 13 randomized controlled trials. Regarding outcomes measured, results showed that aerobic and resistance exercise improved muscle strength, that mind-body PE decreased main symptoms of AN and mental health, and that combined PE reduced dysfunctional exercise and improved weight gain.

CONCLUSION

The findings suggest that ET intervention can induce benefits and has no deleterious effects on patients. In addition, specific effects on anorexia symptoms and physical and mental health have been observed according to the type of PE. However, this review reported several methodological weaknesses, including a lack of control group or randomization and statistical misconduct. Finally, ET intervention parameters were heterogeneous, and ET intervention generally lacked details, making reproducibility and comparability difficult. All these limitations underscore the need for a more rigorous methodology for further research.

Rethinking the Approach to Preclinical Models of Anorexia Nervosa

PURPOSE OF REVIEW

The goal of this review is to describe how emerging technological developments in pre-clinical animal research can be harnessed to accelerate research in anorexia nervosa (AN).

RECENT FINDINGS

The activity-based anorexia (ABA) paradigm, the best characterized animal model of AN, combines restricted feeding, excessive exercise, and weight loss. A growing body of evidence supports the idea that pathophysiological weight loss in this model is due to cognitive inflexibility, a clinical feature of AN. Targeted manipulations that recapitulate brain changes reported in AN - hyperdopaminergia or hyperactivity of cortical inputs to the nucleus accumbens - exacerbate weight loss in the ABA paradigm, providing the first evidence of causality. The power of preclinical research lies in the ability to assess the consequences of targeted manipulations of neuronal circuits that have been implicated in clinical research. Additional paradigms are needed to capture other features of AN that are not seen in ABA.

Low self-esteem predicts orthorexia nervosa, mediated by spiritual attitudes among frequent exercisers

OBJECTIVE

The aim of this study was to measure how orthorexic tendencies relate to age, self-esteem, and spirituality. We conducted the study on a sample of Hungarian adults performing regular fitness activity.

METHOD

175 participants completed a four-part online survey: demographics and training habits, the Rosenberg Self-Esteem Scale, the Eating Habits Questionnaire-Revised (EHQ-R), and one of the Spiritual Awareness questionnaire's subscale. We performed univariate linear regression to assess the predictor role of age on orthorexic tendencies. Mediation analysis was conducted to determine the effect of self-esteem on orthorexic tendencies and the mediator role of spiritual attitudes.

RESULTS

Age negatively correlated with EHQ-R, and there were no gender differences. Lower self-esteem was a predictor for orthorexic tendencies with the total effect of ß = -0.3046 (p < 0.0001). In part, this is a direct relationship, but it is mediated by spiritual awareness as well.

DISCUSSION

Among frequent exercisers, strict dieting is likely to originate from a lack of self-esteem due to perfectionist standards, social comparison, and the aspiration of being in control. In case self-esteem is achieved through spiritual approaches, individuals may experience positive changes in their attitudes toward eating and their bodies as well. In the future, it is important to confirm whether the EHQ-R indicates diagnostic boundaries.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional study.

Registered report: A pilot investigation of acute exercise response among girls and young women with and without eating disorders

OBJECTIVE

Driven exercise (DEx) is a serious and common feature of eating disorders (EDs), but current understanding of factors that give rise to and maintain DEx is limited. DEx may be reinforced through its effects on the threat reduction and reward systems. The current protocol is designed to evaluate acute psychobiological response to exercise among female participants (age 16-22) with and without EDs.

METHOD

Twenty medically-stable participants with restrictive-spectrum EDs and 20 healthy control (HC) participants will complete study screening and three task visits which will include two 30-minute bouts of aerobic exercise.

RESULTS

We aim to validate and demonstrate feasibility of two tasks capturing exercise response in this sample. Further, we will estimate the degree to which a bout of exercise impacts state body image, affect, and circulating concentrations of biological markers among participants, and we will examine whether the impact of exercise on psychological outcomes may differ across ED and HC groups.

DISCUSSION

Completion of this project will contribute to the conceptualization of DEx and how individuals' acute biological and affective responses to exercise contribute to risk for and maintenance of DEx.

Psychosocial etiology of maladaptive exercise and its role in eating disorders: A systematic review

OBJECTIVE

Although maladaptive exercise (ME) is widely recognized as a clinical feature in transdiagnostic eating disorders, less is known about psychosocial factors that give rise to and perpetuate this behavior. This systematic review aimed to examine the empirical status of this association.

METHOD

We reviewed 46 full text articles examining longitudinal associations between psychosocial variables and ME.

RESULTS

Eighteen studies met full inclusion criteria. Based on our qualitative synthesis, evidence suggests reasonably consistent associations between early concern with weight and shape, and negative affect on later development of ME.

DISCUSSION

Inconsistent and insufficient assessment of ME across a majority of studies underscores caution in interpretation of results, but guides important discussion for future clinical and research efforts.

Perfectionism and Difficulty Controlling Thoughts Bridge Eating Disorder and Obsessive-Compulsive Disorder Symptoms: A Network Analysis

BACKGROUND

Eating disorders (ED) and obsessive-compulsive disorder (OCD) are highly comorbid, but little is known about how this comorbidity is maintained. Prior research suggests that obsessive thoughts and perfectionism may be shared maintenance factors for EDs and OCD.

METHODS

The current study used network analysis to (1) identify bridge pathways in an ED-OCD comorbidity network and (2) test if perfectionism symptoms bridge between ED-OCD symptoms in a combined network model including ED, OCD, and Perfectionism symptoms. Participants (N = 1,619) were a mixed sample of undergraduate students and individuals diagnosed with EDs.

RESULTS

Difficulty controlling thoughts was the symptom with the highest bridge centrality in both models, connecting with ED-related worry and doubts. In the ED-OCD-Perfectionism comorbidity network, doubts about simple everyday things and repeating things over and over bridged between ED and OCD symptoms. Additionally, specific and distinct pathways were identified between OCD and two types of ED pathology: restricting (checking compulsions and rigidity around food) and binge eating (hoarding and binge eating symptoms).

LIMITATIONS

Due to the cross-sectional nature of the data, no directional inferences can be made. Due to a higher OCD symptom prevalence rate than reported in previous studies, our undergraduate sample may not be representative of other college populations.

CONCLUSIONS

The presence of intrusive cognitions and maladaptive perfectionism may contribute to the maintenance of co-occurring ED and OCD symptoms. These findings begin to delineate specific pathways among OCD and ED symptoms, which can be used in the development of interventions to disrupt connections among these disorders.

Eating disorders with over-exercise: A cross-sectional analysis of the mediational role of problematic usage of the internet in young people

Eating disorders are widespread illnesses with significant global impact. There is growing concern about how young people overuse online resources leading to mental health sequelae. We gathered data from 639 individuals from a population cohort. Participants were all young adults at the point of contact and were grouped as having probable eating disorder with excessive exercise (n = 37) or controls (n = 602). We measured obsessionality, compulsivity, impulsivity, and problematic internet use. Group differences in these domains were evaluated; and structural equation modelling (SEM) was used to assess structural relationships between variables. Cases had higher scores of obsessional thoughts of threat (Cohen's d = 0.94, p < 0.001), intolerance towards uncertainty (Cohen's d = 0.72; p < 0.001), thoughts of importance and control (Cohen's d = 0.65, p < 0.01), compulsivity (Cohen's d = 0.72; p < 0.001), negative urgency (Cohen's d = 0.75, p < 0.001), and higher problematic usage of the internet (Cohen's d = 0.73; p-corrected <0.001). Our SEM showed significant partial mediation of problematic internet use on both the effect of obsessionality latent factor on cases (z-value = 2.52, p < 0.05), as well as of sensation seeking latent factor on cases (z-value = 2.09, p < 0.05). Youth with eating disorder and heightened exercise levels have increased obsessive thoughts of threat, compulsivity traits and sensation seeking impulsivity. The association between obsessive thoughts and eating disorders, as well as sensation seeking and eating disorders were partially mediated by problematic internet use. Problematic internet use may be playing a role in the development or maintenance of eating disorder symptoms in the background of obsessional thoughts and sensation seeking impulsive traits.

Psychometric properties of instruments assessing exercise in patients with eating disorders: a systematic review

BACKGROUND

Research has identified factors specific to exercise in eating disorder patients such as affect regulation and compulsivity. Existing measures of exercise behaviour which were not originally designed for eating disorder patients may not adequately assess these factors. The aim of this systematic review is to identify and assess the psychometric properties of all self-report measures of exercise designed to be used with eating disorder patients.

METHOD

A systematic review was conducted following the PRISMA guidelines. MedLine, Scopus and PsycINFO were systematically searched. A total of 12 studies examining two measures, the Exercise and Eating Disorders and the Compulsive Exercise Test, met inclusion criteria.

RESULTS

Validation studies showed promising results for both tests and established internal consistency, concurrent and convergent validity, and construct validity. The factor structure of the Compulsive Exercise Test was not confirmed in the majority of the studies included in this review, while there are only two studies conducting factor analysis on the Exercise and Eating Disorders.

CONCLUSION

The two measures identified by this systematic review represent the current research on measures of compulsive exercise for eating disorder patients. Further research is needed to confirm a factor structure and validate both the Compulsive Exercise Test and the Exercise and Eating Disorders in more diverse clinical samples.

Might Starvation-Induced Adaptations in Muscle Mass, Muscle Morphology and Muscle Function Contribute to the Increased Urge for Movement and to Spontaneous Physical Activity in Anorexia Nervosa?

Severely undernourished and underweight anorexia nervosa (AN) patients typically remain active and mobile. Might such persistent physical activity in AN be supported by specific adaptations in muscle tissue during long term undernutrition? To identify potential differences, studies examining the effects of undernutrition on skeletal muscle mass, muscle morphology and muscle function in healthy humans and in AN patients were reviewed. Adjustments in muscle morphology and function in AN did not differ in substance from those in healthy humans, undernourished people, or undergoing semi-starvation. Loss of muscle mass, changes in muscle contractility and atrophy of muscle fibers (predominantly type II fibers) characterized both groups. Muscle innervation was unaffected. Work capacity in men in semi-starvation experiments and in females with AN declined by about 70% and 50%, respectively. Perceptions of fatigue and effort distinguished the groups: signs of general weakness, tiring quickly and avoidance of physical activity that were recorded in semi-starvation were not reported for AN patients. The absence of distinctive starvation-related adjustments in skeletal muscle in AN suggests that new methods, such as muscle gene expression profiles in response to deficient nutrient intake, and better knowledge of the central regulatory circuitries contributing to motor urgency will be required to shed light on the persistent mobility in AN patients.

Avoidance coping during mealtimes predicts higher eating disorder symptoms

OBJECTIVE

Eating disorders (EDs) are characterized by significant anxiety during mealtime that contributes to food avoidance and weight loss. Individuals with EDs commonly use avoidance coping (e.g., distraction) to tolerate meals and comply with meal plans. Although this strategy may be effective short term, a large body of anxiety literature suggests that avoidance can lead to worsening of psychological symptoms long term.

METHOD

The current study (N = 66 individuals diagnosed with ED) used ecological momentary assessment (EMA) to examine the short-term and long-term associations of avoidance coping on ED symptoms.

RESULTS

Distraction during meals predicted a reduction in anxiety in the short term, and both distraction and avoidance of emotions predicted increases in excessive exercise in the short term. Distraction and avoidance of emotions predicted increases in bulimic symptoms 1 month after completion of EMA.

DISCUSSION

These results are consistent with prior literature on avoidance and suggest that avoidance coping during meals may contribute to the increase of ED behaviors in the long term. Coping strategies that encourage approach and tolerance of difficult thoughts and emotions (e.g., acceptance-based strategies) rather that avoidance coping may promote longer-term symptom reduction.

Dopaminergic activity and exercise behavior in anorexia nervosa

Driven exercise (i.e., the tendency to exercise in excess to influence weight/shape or regulate emotion) is difficult to manage in the context of anorexia nervosa, and is associated with poorer treatment outcomes, and psychological and medical severity. Driven exercise is observed in a considerable number of those diagnosed with anorexia nervosa; however, to date, this hallmark symptom remains poorly understood. Dopamine signaling is implicated in motivating and maintaining appetitive behavior among patients with eating disorders; but, much less is known about the role of dopamine signaling specific to the symptom of driven exercise. An improved understanding of this biobehavioral mechanism may inform the etiology of driven exercise in anorexia nervosa, with the potential to impact future research and treatment efforts. This review describes the role that dopamine serves in maintaining symptoms in the context of anorexia nervosa, and synthesizes current relevant evidence on exercise in AN and related dopaminergic activity. Throughout, theoretical implications are discussed, along with critical directions for future research.

Physical Activity in Eating Disorders: A Systematic Review

Abnormally high levels of physical activity have been documented throughout the literature in patients with eating disorders (ED), especially those diagnosed with anorexia nervosa (AN). Yet no clear definition, conceptualization, or treatment of the problematic use of physical activity (PPA) in ED patients exists. The aim of this review is to propose a new classification of PPA, report the prevalence, triggers, predictors, maintainers and other related factors of PPA in ED patients, in addition to proposing a comprehensive model of the development of PPA in AN. A total of 47 articles, retrieved from Medline and Web of Science, met the inclusion criteria and were included in the analysis. As a result, the new approach of PPA was divided into two groups (group 1 and group 2) according to the dimension (quantitative vs qualitative approach) of physical activity that was evaluated. The prevalence of PPA in ED was reported in 20 out of 47 studies, the comparison of PPA between ED versus controls in 21 articles, and the links between PPA and psychological factors in ED in 26 articles, including depression (16/26), anxiety (13/26), obsessive–compulsiveness (9/26), self-esteem (4/26), addictiveness (1/26), regulation and verbal expression of emotions (1/26) and anhedonia (1/26). The links between PPA and ED symptomatology, PPA and weight, body mass index (BMI) and body composition in ED, PPA and age, onset, illness duration and lifetime activity status in ED, PPA and ED treatment outcome were reported in 18, 15, 7, 5 articles, respectively. All of the factors have been systematically clustered into group 1 and group 2. Results focused more on AN rather than BN due to the limited studies on the latter. Additionally, a model for the development of PPA in AN patients was proposed, encompassing five periods evolving into three clinical stages. Thus, two very opposite components of PPA in AN were suggested: voluntarily PPA increased in AN was viewed as a conscious strategy to maximize weight loss, while involuntarily PPA increased proportionally with weight-loss, indicating that exercise might be under the control of a subconscious biological drive and involuntary cognition.

Compulsive exercise or exercise dependence? Clarifying conceptualizations of exercise in the context of eating disorder pathology

OBJECTIVE

Maladaptive exercise relates to eating disorder (ED) pathology and impairment in clinical and non-clinical populations. At present, two different conceptualizations of maladaptive exercise are often studied in relation to ED pathology: compulsive exercise and exercise dependence. Compulsive exercise functions to avoid negative affect (e.g., guilt and anxiety) associated with not exercising, whereas exercise dependence is associated with tolerance to exercise benefits and avoidance of exercise withdrawal. At present, clinicians and researchers struggle to determine the most appropriate term for describing problematic exercise in individuals with ED pathology. This study aimed to directly compare these conceptualizations of maladaptive exercise in relation to severity of ED pathology.

DESIGN

This study examined cross-sectional data.

METHOD

Undergraduate participants (N =235, 78% female) with elevated ED pathology completed the Eating Disorder Examination Questionnaire (EDE-Q), Compulsive Exercise Test (CET), and Exercise Dependence Scale (EDS). Multiple linear regression analyses evaluated associations between EDE-Q and CET and EDS scores and dominance analysis determined which qualities of exercise were uniquely associated with EDE-Q scores.

RESULTS

Results suggest that compulsive qualities of exercise, including exercise to control shape and weight and to avoid negative affect are more strongly associated with severity of ED pathology than qualities of exercise dependence.

CONCLUSIONS

Clinicians and researchers working with ED populations can benefit from prioritizing assessments that capture compulsive qualities of exercise. Additionally, these results suggest that interventions that effectively target other compulsive behaviors (e.g., exposure and response prevention) may be promising treatment options for problematic exercise in the context of EDs.

Pilot study of a personality-based approach to assessing eating disorder and Obsessive Compulsive Disorder symptom risk in college men and women

Objective: To conduct a pilot test of the validity of using empirically derived personality types to characterize eating disorder (ED) risk in college students and resolve discrepancies regarding the role of perfectionism and obsessive-compulsive disorder (OCD) symptoms.Participants: Man and woman undergraduate students (N = 169) at a small, private university. Data were collected from February to May 2016 and 2018. Methods: Participants completed self-report measures of personality (perfectionism, impulsivity, and effortful control) and psychopathology (EDs, OCD). Results: Our analyses replicated three validated personality types: overcontrolled, undercontrolled, and resilient. Analysis of variances demonstrated perfectionism, ED, and OCD symptoms were significantly elevated in the overcontrolled subtype. There was no interaction by sex. Conclusions: These findings suggest that personality types may be useful for classifying ED risk and OCD symptoms in college students across sexes. Further study and relevance to prevention and intervention efforts to reduce the burden of EDs on college campuses will be discussed.

An unhealthy health behavior: analysis of orthorexic tendencies among Hungarian gym attendees

AIM

In the present study, we aim to assess the prevalence and certain psychological and other correlates of orthorexic tendencies: health and exercise behaviors and demographic variables among gym attendees in Hungary.

METHODS

Altogether, responses of 207 gym attendees who filled out an online questionnaire (03/2017-10/2017) were analyzed. The mean age was 31.9 years; most were female and college educated, and about half resided in the capital city. Frequencies and means were calculated for the sample; and univariate linear regression and ANOVA were carried out. Finally, multivariate linear regression was used to assess the relationship between the dependent variable (Orto-11-Hu) and the independent variables (Eating Disorder Inventory, Maudsley Obsessional-Compulsive Inventory, health and exercise habits, and demographics).

RESULTS

The mean score for the Orto-11-Hu was 27.7. In the multivariate analysis, two eating disorder characteristics (drive for thinness and interpersonal distrust), age, exercising more than once a day, and yoga practice were significantly associated with higher orthorexic tendencies. There was a lack of correlation between any obsessive-compulsive traits.

CONCLUSIONS

Our data suggest and overlap between certain eating disorder traits, and a link between ON and frequent exercising and younger age. Further research is needed to investigate whether these correlates are found not only in a specific fitness-oriented population, but also in the general population.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional study.

Not the Function of Eating, but Spontaneous Activity and Energy Expenditure, Reflected in "Restlessness" and a "Drive for Activity" Appear to Be Dysregulated in Anorexia Nervosa: Treatment Implications

Anorexia nervosa (AN) is uncommon as a syndrome, despite widespread dieting or voluntary food restriction, especially among female adolescents. This suggests that restriction of caloric intake might not be the only component driving weight loss in AN. Historical observations and experimental evidence from energy expenditure studies and recordings from movement sensors reviewed in this paper reveal that AN is associated with motor activity levels and with an energy output not significantly different from that in normal-weight healthy age-matched controls. By contrast, other conditions of prolonged caloric under-nutrition are typically associated with loss of energy, slowing of movements and a decrease in self-initiated activity and well-being. Several hypotheses can be inferred from the findings: (a) that long term severe caloric restriction fails in downregulating movements and energy expenditure in AN. (b) Clinically and subjectively observable as mental and physical restlessness and continued motor activity, this restless energy, differing in intensity, seems to serve as the permissive factor for and possibly to drive exercise and hyperactivity in AN. (c) Such restless energy and increased arousal, generated sometime in the course of the weight loss process, appear to enhance the person's self-perception and wellbeing, to heighten proprioception, to intensify body awareness and to improve self-esteem. (d) Restlessness and continued motor activity may constitute a phenotype of AN. The therapeutic value of the concept of an abnormality in the energy regulatory system, likely the result of a host of genetic and epigenetic changes in AN, lies primarily in its heuristic and explanatory power and its potential for disease prevention. Restless energy as a permissive and important component for the development and in the maintenance of AN, does not fundamentally alter treatment, since prolonged food deprivation is the principal causal factor for the development of AN. Re-nutrition within a structured treatment plan, to include individual and family therapy and, if indicated, heat application, remains the most effective symptomatic treatment for AN. Corroboration of the concept of restless activation will require the patient's cooperation and input to identify and capture more precisely the experiences, sensations, and changes that allow the emaciated patient to remain mobile and active.

Evaluating anhedonia in the activity-based anorexia (ABA) rat model

Patients suffering anorexia nervosa (AN) become anhedonic, in other words, unable or unwilling to derive normal pleasures and avoid rewarding outcomes, most profoundly in food intake. The neurobiological underpinnings of anhedonia are likely to involve mesolimbic reward circuitry. We propose here that this circuitry and its involvement in AN can be investigated using the activity-based anorexia (ABA) rodent model that recapitulates many of the characteristics of the human condition, most notably rapid weight loss. Preference for sweetened water was used to assay hedonic processing in female Sprague-Dawley rats exposed to the ABA protocol, which involves free access to running wheels paired with time-limited access to food. This protocol uncovered a transient anhedonia in only one quarter of cases; however, exposure to running wheels alone was associated with a rapid aversion to sweetened water (F_{1.833, 20.17} = 78.29, p < .0001), and time-limited food access alone did not impact preference (F_{2.205, 24.25} = 0.305, p = .761). High levels of running wheel activity prior to the onset of food restriction increased susceptibility to body weight loss in ABA (F_10,196.129 = 2.069, p = .029) and food anticipatory activity predicted subsequent food intake only for rats that were resistant to body weight loss (r = 0.44, p = .001). These data are inconsistent with the hypothesis that anhedonia underscores the precipitous weight loss in ABA, however, they highlight the predictive nature of hyperactivity in susceptibility to the ABA paradigm. These results will help inform the neurobiological framework of ABA and provide insight into the mechanisms of reward relevant to feeding and weight loss.

Successful use of electroconvulsive therapy in a patient with anorexia nervosa and severe acute-onset obsessive-compulsive disorder

Anorexia nervosa (AN) is a complex condition that is often accompanied by several serious comorbidities that may require a variety of treatment modalities throughout the course of the illness. Obsessive-compulsive disorder (OCD), which is common in patients with AN, may occasionally cause serious interruptions to the daily functioning of the patient. We report on a 24-year-old male patient with chronic AN. During the beginning of his illness, he had a major depressive episode that was followed by AN onset. Throughout his illness, he also experienced chronic moderate depressive symptoms and later developed severe OCD. He experienced complete remission from the OCD and an improved mood after undergoing a course of bilateral electroconvulsive therapy (ECT). His OCD symptoms did not recur during the first year of follow-up. ECT may prove to be a fast and effective treatment strategy for severe and disabling acute-onset OCD that occurs during the course of comorbid AN. The case described herein shows how a comorbid psychiatric disorder in a patient suffering from chronic AN may disrupt the daily functioning of the patient if it is not urgently treated.

Cost-based anorexia: A novel framework to model anorexia nervosa

Anorexia nervosa (AN) is an eating disorder that is thought to emerge through biological predisposition(s) within sociocultural context(s). Practical and ethical concerns limit study of the etiology of this disorder in humans, and in particular the biological aspects. Laboratory animal models have a pivotal role in advancing our understanding of the neurobiological, physiological and behavioral aspects of this disorder, and developing new treatment strategies. One shortcoming of animal models, including activity based anorexia (ABA) in rodents, is that they cannot fully capture the contextual aspects of AN. In this article we discuss the merits of an alternate approach, cost-based anorexia (CBA). CBA is conceptually founded in behavioral economics and its magnitude is influenced by several relevant contextual aspects of feeding.

Exercise addiction in adolescents and emerging adults - Validation of a youth version of the Exercise Addiction Inventory

Background Behavioral addictions often onset in adolescence and increase the risk of psychological and social problems later in life. The core symptoms of addiction are tolerance, withdrawal symptoms, lack of control, and compulsive occupation with the behavior. Psychometrically validated tools are required for detection and early intervention. Adolescent screening instruments exist for several behavioral addictions including gambling and video gaming addiction but not for exercise addiction. Given recent empirical and clinical evidence that a minority of teenagers appear to be experiencing exercise addiction, a psychometrically robust screening instrument is required. Aims The aim of this study was to develop and test the psychometric properties of a youth version of the Exercise Addiction Inventory (EAI) - a robust screening instrument that has been used across different countries and cultures - and to assess the prevalence of exercise addiction and associated disturbed eating. Methods A cross-sectional survey was administered to three high-risk samples (n = 471) aged 11-20 years (mean age: 16.3 years): sport school students, fitness center attendees, and patients with eating disorder diagnoses. A youth version of the EAI (EAI-Y) was developed and distributed. Participants were also screened for disordered eating with the SCOFF Questionnaire. Results Overall, the EAI-Y demonstrated good reliability and construct validity. The prevalence rate of exercise addiction was 4.0% in school athletes, 8.7% in fitness attendees, and 21% in patients with eating disorders. Exercise addiction was associated with feelings of guilt when not exercising, ignoring pain and injury, and higher levels of body dissatisfaction.

Relationships between compulsive exercise, quality of life, psychological distress and motivation to change in adults with anorexia nervosa

BACKGROUND

For people with anorexia nervosa (AN), compulsive exercise is characterized by extreme concerns about the perceived negative consequences of stopping/reducing exercise, dysregulation of affect, and inflexible exercise routines. It is associated with increased eating disorder psychopathology and poor clinical outcome. However, its relationships with two important clinical issues, quality of life (QoL) and motivation to change, are currently unknown. This study aimed to assess the cross-sectional relationships between compulsive exercise, QoL, psychological distress (anxiety and depressive symptoms, and obsessive-compulsive traits) and motivation to change in patients with AN.

METHOD

A total of 78 adults with AN participated in this study, which was nested within a randomized controlled trial of psychological treatments for AN. At baseline (pre-treatment), participants completed questionnaires assessing compulsive exercise, eating disorder (ED) psychopathology, QoL, psychological distress and motivation to change.

RESULTS

Baseline correlational analyses demonstrated a moderate positive relationship between compulsive exercise and ED psychopathology, and a weak positive relationship between compulsive exercise and psychological distress. There was a moderate negative relationship between compulsive exercise and eating disorder QoL.

CONCLUSIONS

These results indicate compulsive exercise is moderately associated with poorer QoL and weakly associated with higher distress. Targeting compulsive exercise in the treatment of anorexia nervosa may help reduce the burden of illness and improve patients' engagement in treatment.

TRIAL REGISTRATION

ACTRN12610000585022. Taking a LEAP forward in the treatment of anorexia nervosa: a randomized controlled trial. NHMRC grant: 634922.

Compulsive exercise in eating disorders: proposal for a definition and a clinical assessment

BACKGROUND

Compulsive exercise has been recognized as a highly prevalent symptom in eating disorders (ED) for over 100 years and is associated with poor short-term and long-term treatment outcome. Progress in understanding and treatment of compulsive exercise will remain limited as long as no consensus framework for definition and assessment of compulsive exercise exists, as results cannot be compared across clinical studies.Based on existing literature, it was our aim to propose a transdiagnostic definition and a clinical assessment for compulsive exercise, that can be applied to adolescent and adult patients with ED.

METHOD

During a series of meetings of experienced clinicians at a highly specialized hospital for eating disorders, we elaborated a transdiagnostic definition of compulsive exercise in ED. Additionally, we derived a clinical interview for the assessment of compulsive exercise and its different subtypes.

RESULTS

The core criterion when defining and assessing compulsive exercise is a pathologically increased exercise pattern characterized by 1) excessive exercise that a patient feels driven to perform in response to an obsession or according to rules that must be applied rigidly, and 2) exercise that is aimed at preventing or reducing distress or at preventing some dreaded consequence. A second necessary criterion is the physical or psychological burden caused by compulsive exercise, i.e., that it is time-consuming, significantly interferes with the patient's daily routine, occupational functioning or social relationships or is continued despite medical injury, illness, or lack of enjoyment. Insight that compulsive exercise is excessive or unreasonable was added as an optional criterion.Compulsive exercise manifests itself in three different subtypes: 1) vigorous exercise, 2) marked increase in daily movement, or 3) motor restlessness.The above criteria must be met during the past 6 months, together with one of the three subtypes of compulsive exercise.

CONCLUSIONS

The proposed criteria aim to foster the discussion around definition and assessment of compulsive exercise with the goal of reaching an international consensus in the near future.Providing a consistent framework for researchers and clinicians would considerably advance understanding and treatment of compulsive exercise in ED patients.

Specialized group intervention for compulsive exercise in inpatients with eating disorders: feasibility and preliminary outcomes

BACKGROUND

Patients with eating disorders (ED) often suffer from compulsive exercise behavior, which is associated with lower short-term response to treatment and poorer long-term outcome. Evidence-based interventions specifically targeting compulsive exercise behavior have been scarce so far. We developed a manualized group therapeutic approach integrating cognitive-behavioral therapy, exercise therapy and exposure with response management to promote healthy exercise behavior. Our objective was to examine the feasibility and acceptance of this new approach as add-on to regular inpatient treatment in a pilot study. Additionally, we wanted to estimate preliminary effect sizes.

METHODS

Thirty-two female, adolescent and adult eating disordered inpatients were recruited. According to the 4th ed. of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), twenty-six patients met criteria for Anorexia nervosa (AN), two for Bulimia nervosa and four for eating disorder not otherwise specified. Semi-structured interviews were conducted for qualitative evaluation of feasibility and acceptance of the new intervention. Patients completed the Commitment to Exercise Scale (CES) and the Compulsive Exercise Test (CET) for assessment of compulsive exercise, the Eating Disorder Inventory-2 for assessment of eating disorder pathology, the Beck Depression Inventory-II and Brief Symptom Inventory for assessment of depressive and general psychopathology and the Emotion Regulation Skills Questionnaire for assessment of emotion regulation before the beginning and at the end of the group intervention. Additionally, weight gain was monitored.

RESULTS

Feasibility of our approach was confirmed. All patients reported a high satisfaction with both structure and content of the group. Between pre- and post-intervention, patients showed significant reductions in compulsive exercise (effect size CES: 1.44; effect size CET total: 0.93), drive for thinness (effect size: 0.48), depressive symptoms (effect size: 0.36), general psychopathology (effect size: 0.29) and acceptance of emotions (effect size: - 0.62). Patients with AN also showed significant mean weight gain during the intervention (effect size: - 0.44).

CONCLUSIONS

Results of our pilot study indicate that our integrative approach to compulsive exercise in ED patients might represent a promising new therapeutic option. Feasibility and acceptance of the intervention were confirmed. Preliminary effect sizes on most outcomes were promising. As improvements in Body-mass-index, eating disorder and general psychopathology are also to be expected by routine inpatient treatment, a large randomized trial is currently underway to evaluate the efficacy of this new intervention.

Validity of Exercise Measures in Adults with Anorexia Nervosa: The EDE, Compulsive Exercise Test and Other Self-Report Scales

OBJECTIVE

Compulsive exercise is a prominent feature for the majority of patients with Anorexia Nervosa (AN), but there is a dearth of research evaluating assessment instruments. This study assessed the concurrent validity of the exercise items of the Eating Disorder Examination (EDE) and Eating Disorder Examination-Questionnaire (EDE-Q), with the Compulsive Exercise Test (CET) and other self-report exercise measures in patients with AN. We also aimed to perform validation of the CET in an adult clinical sample.

METHODS

The sample consisted of 78 adults with AN, recruited for the randomized controlled trial "Taking a LEAP forward in the treatment of anorexia nervosa." At baseline, participants completed the EDE, EDE-Q, CET, Reasons for Exercise Inventory (REI), Commitment to Exercise Scale (CES) and Exercise Beliefs Questionnaire (EBQ). Correlational and regression analyses were performed.

RESULTS

EDE exercise days and exercise time per day were positively correlated with each other and with all CET subscales (except Lack of exercise enjoyment), CES mean, EBQ total and REI total. Exercise time per day was associated with a higher EDE global score. The CET demonstrated good concurrent validity with the CES, the REI and the EBQ. Of the self-reports, the CET explained the greatest variance in eating disorder psychopathology and demonstrated good to excellent reliability in this sample.

DISCUSSION

The EDE and EDE-Q demonstrated good concurrent validity with the CET. Further research is required to evaluate the CET's factor structure in a large clinical sample. However, the CET has demonstrated strong clinical utility in adult patients with AN. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:533-541).

Behavioral and psychological aspects of exercise across stages of eating disorder recovery

This study examined the relationship between behavioral and psychological aspects of exercise and eating disorder recovery. Participants were categorized as having an eating disorder (n = 53), partially recovered (n = 15), fully recovered (n = 20), or non-eating disorder controls (n = 67). Groups did not differ significantly in time spent exercising, but did differ in exercise intensity, guilt-related exercise, obsessive exercise cognitions, and appearance/weight management and stress/mood management motivations for exercise. Results support the importance of measuring psychological aspects of exercise in particular across the course of an eating disorder.

Identifying the features of an exercise addiction: A Delphi study

Objectives There remains limited consensus regarding the definition and conceptual basis of exercise addiction. An understanding of the factors motivating maintenance of addictive exercise behavior is important for appropriately targeting intervention. The aims of this study were twofold: first, to establish consensus on features of an exercise addiction using Delphi methodology and second, to identify whether these features are congruous with a conceptual model of exercise addiction adapted from the Work Craving Model. Methods A three-round Delphi process explored the views of participants regarding the features of an exercise addiction. The participants were selected from sport and exercise relevant domains, including physicians, physiotherapists, coaches, trainers, and athletes. Suggestions meeting consensus were considered with regard to the proposed conceptual model. Results and discussion Sixty-three items reached consensus. There was concordance of opinion that exercising excessively is an addiction, and therefore it was appropriate to consider the suggestions in light of the addiction-based conceptual model. Statements reaching consensus were consistent with all three components of the model: learned (negative perfectionism), behavioral (obsessive-compulsive drive), and hedonic (self-worth compensation and reduction of negative affect and withdrawal). Conclusions Delphi methodology allowed consensus to be reached regarding the features of an exercise addiction, and these features were consistent with our hypothesized conceptual model of exercise addiction. This study is the first to have applied Delphi methodology to the exercise addiction field, and therefore introduces a novel approach to exercise addiction research that can be used as a template to stimulate future examination using this technique.

Evaluation of the Compulsive Exercise Test (CET) in Adolescents with Eating Disorders: Factor Structure and Relation to Eating Disordered Psychopathology

OBJECTIVE

The aims of this study were to explore the factor structure of the Compulsive Exercise Test (CET) in a clinical sample of Swedish adolescents with eating disorders (ED) and to study the relationship of CET with ED cognitions, body weight and exercise frequency.

METHODS

The compulsive Exercise Test, the Eating Disorders Examination-Questionnaire, body mass index (BMI) and exercise frequency were available at assessment of 210 adolescents (age 14.4 ± 1.6 years) with ED.

RESULTS

Factor analysis generated four factors with close similarity to factors previously obtained in a community sample of adolescents samples and supported the use of the original version of CET. Exercise for weight control was strongly related to ED cognitions but less to exercise frequency and BMI. Exercise for regulation of mood was related to ED cognitions and exercise frequency but not to BMI.

DISCUSSION

In adolescents with ED, different aspects of exercise are related to ED cognitions. This needs addressing in the treatment of adolescents with ED. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

Problematic Exercise in Anorexia Nervosa: Testing Potential Risk Factors against Different Definitions

“Hyperactivity” has a wide prevalence range of 31% to 80% in the anorexia nervosa literature that could be partly due to the plethora of definitions provided by researchers in this field. The purpose of this study was two-fold: 1) To assess the variance across prevalence rates of problematic exercise encountered in patients with anorexia nervosa, in relation to seven different definitions found in the literature. 2) To examine how core eating disorder symptoms and the dimensions of emotional profile are associated with these different definitions and the impact of these definitions on the assessment of patients’ quality of life. Exercise was evaluated in terms of duration, intensity, type and compulsion using a semi-structured questionnaire administered to 180 women suffering from severe anorexia nervosa. Seven different definitions of problematic exercise were identified in the literature: three entailing a single dimension of problematic exercise (duration, compulsion or intensity) and four combining these different dimensions. Emotional profile scores, obsessive-compulsive symptoms, eating disorder symptomatology, worries and concerns about body shape, self-esteem and quality of life were assessed using several established questionnaires. The prevalence of problematic exercise varied considerably from, 5% to 54%, depending on the number of criteria used for its definition. The type and level of eating disorder symptomatology was found to be associated with several definitions of problematic exercise. Surprisingly, a better self-reported quality of life was found among problematic exercisers compared to non-problematic exercisers in three of the definitions. The different definitions of problematic exercise explain the broad prevalence ranges and the conflicting associations generally reported in the literature between problematic exercise and eating disorder-related psychological parameters. There is an urgent need for a valid consensus on the definition of problematic exercise in anorexia nervosa. This will support the development of further research on the etiology and treatment of problematic exercise.

Comparison of Perfectionism and Related Positive-Negative Dimension in People With High Traits on Obsessive Compulsive and Eating Disorder Characteristics

BACKGROUND

Psychopathological perfectionism is often correlated with obsessive compulsive eating disorders.

OBJECTIVES

The purpose of this study was to investigate perfectionism in people with high traits of obsessive compulsive and eating disorder characteristics.

MATERIALS AND METHODS

This study was an expo fact research. The statistical population of the research comprised of male and female undergraduate students at Tabriz and Sarab branches of Payam- e- Noor University, Tabriz Islamic University and Azarbaijan Shahid Madani university in the academic year 2012 - 2013. A group of 640 university students, using the stratified random sampling method were screened by the obsessive compulsive inventory and the eating attitude test, then a group of 143 participants with high obsessive compulsive traits with another 137 participants with high eating disorder characteristics were selected and assessed with the Perfectionism Inventory. Data were analyzed using one way analysis of variance.

RESULTS

The results showed that perfectionism and related negative dimension are more commonly found in people with high obsessive-compulsive traits than eating disorder characteristics (P < 0.02). The results showed the highest contribution of maladaptive perfectionism in predicting obsessive-compulsive features and pathological eating attitude. Also, no difference was found between the two groups in terms of negative perfectionism.

CONCLUSIONS

The greater association of perfectionism with symptoms of obsessive-compulsive is consistent with its phenomenological feature. Fear of failure may motivate the behavioral components of perfectionism that aim to focus on careful checking, reassurance seeking and excessive consideration before making a decision.

Melanin-concentrating hormone is necessary for olanzapine-inhibited locomotor activity in male mice

Olanzapine (OLZ), an atypical antipsychotic, can be effective in treating patients with restricting type anorexia nervosa who exercise excessively. Clinical improvements include weight gain and reduced pathological hyperactivity. However the neuronal populations and mechanisms underlying OLZ actions are not known. We studied the effects of OLZ on hyperactivity using male mice lacking the hypothalamic neuropeptide melanin-concentrating hormone (MCHKO) that are lean and hyperactive. We compared the in vivo effects of systemic or intra-accumbens nucleus (Acb) OLZ administration on locomotor activity in WT and MCHKO littermates. Acute systemic OLZ treatment in WT mice significantly reduced locomotor activity, an effect that is substantially attenuated in MCHKO mice. Furthermore, OLZ infusion directly into the Acb of WT mice reduced locomotor activity, but not in MCHKO mice. To identify contributing neuronal mechanisms, we assessed the effect of OLZ treatment on Acb synaptic transmission ex vivo and in vitro. Intraperitoneal OLZ treatment reduced Acb GABAergic activity in WT but not MCHKO neurons. This effect was also seen in vitro by applying OLZ to acute brain slices. OLZ reduced the frequency and amplitude of GABAergic activity that was more robust in WT than MCHKO Acb. These findings indicate that OLZ reduced Acb GABAergic transmission and that MCH is necessary for the hypolocomotor effects of OLZ.

The Freiburg sport therapy program for eating disordered outpatients: a pilot study

PURPOSE

Many patients with anorexia or bulimia nervosa use physical activity as a method to influence weight and shape and/or exercise in a compulsive manner. This form of exercising is associated with a more severe illness and higher relapse rates. In a proof-of-concept study, effects of a newly developed sport therapy program aiming to reduce unhealthy exercising were assessed.

METHODS

Thirty-six patients with eating disorders took part in four group terms of the program, each lasting 3 months. They were compared to a matched control group. Main outcome criterion was a reduction in the total score of the commitment to exercise scale (CES).

RESULTS

In the completer analysis, we found statistically significant reductions in the CES total score over time (time × group; p = 0.003) and significant improvements in overall eating psychopathology and quality of life (pre → post). The dropout rate was high (34 %), mainly due to external reasons (time schedule, etc.).

CONCLUSIONS

Findings point to specific effects of a newly developed outpatient sport therapy program for eating disorders. Detailed assessments of patients before assigning them to the program will be necessary to reduce dropout rates. The next step has to be a randomized controlled study.

Anorexia nervosa as a motivated behavior: Relevance of anxiety, stress, fear and learning

The high comorbidity between anorexia nervosa (AN) and anxiety disorders is well recognized. AN is a motivated behavioral disorder in which habit formation is likely to contribute to the persistence of abnormal eating and exercise behaviors. Secondary alterations in brain circuitry underlying the reward value of food and exercise, along with disturbances in neuroendocrine hunger and satiety signaling arising from starvation and excessive exercise, are likely contributors to the maintenance of anorectic behaviors in genetically vulnerable individuals. The potential role of fear conditioning in facilitating onset of AN, or of impaired fear extinction in contributing to the high relapse rates observed following weight restoration, is of interest. Evidence from animal models of anxiety and human laboratory studies indicate that low estrogen impairs fear extinction. Low estradiol levels in AN may therefore play a role in perpetuating fear of food and fat in recently weight restored patients. Translational models including the activity based anorexia (ABA) rodent model of AN, and neuroimaging studies of fear extinction and conditioning, could help clarify the underlying molecular mechanisms and neurocircuitry involved in food avoidance behaviors in AN. Moreover, the adaptation of novel treatment interventions with efficacy in anxiety disorders may contribute to the development of new treatments for this impairing disorder.

Metabolic imaging of deep brain stimulation in anorexia nervosa: a 18F-FDG PET/CT study

OBJECTIVES

Anorexia nervosa (AN), a disorder of unknown etiology, has the highest mortality rate of any psychiatric disorder. Drawing the brain metabolic pattern of AN may help to target the core biological and psychological features of the disorder and to perfect the diagnosis and recovery criteria. In this study, we used 18F-FDG PET to show brain metabolic network for AN.

METHODS

Glucose metabolism in 6 AN patients and 12 age-matched healthy controls was studied using 18F-FDG PET. SPM2 was used to compare brain metabolism in AN patients with that in healthy controls. Four of 6 AN patients took deep brain stimulation (DBS) targeted in nucleus accumbens (NAcc). About 3 to 6 months after the surgery, the 4 AN patients took another 18F-FDG PET scan to assess the change in brain glucose metabolism.

RESULTS

The SPM (statistical parametric mapping ) analysis showed hypermetabolism in the frontal lobe (bilateral, BA10, BA11, BA47), the limbic lobe (bilateral, hippocampus, and amygdala), lentiform nucleus (bilateral), left insula (BA13), and left subcallosal gyrus (BA25). It also showed hypometabolism in the parietal lobe (bilateral, BA7, BA40). The hypermetabolism in frontal lobe, hippocampus, and lentiform nucleus decreased after NAcc-DBS.

CONCLUSIONS

The changes in brain glucose metabolism illustrated the brain metabolic pattern in AN patients. Furthermore, the pattern can be modulated by NAcc-DBS, which confirmed specificity of the pattern. The regions with altered metabolism could interconnect to form a network and integrate information related to appetite. Our study may provide information for targeting the potential candidate brain regions for understanding the pathophysiology of AN and assessing the effects of existing and future treatment approaches.

Eating disorders among patients incarcerated only for repeated shoplifting: a retrospective quasi-case-control study in a medical prison in Japan

BACKGROUND

Shoplifting is a serious problem among patients with eating disorders. For more than a decade, we have treated many patients with eating disorders incarcerated in Hachioji Medical Prison only for repeated shoplifting.

METHODS

We analyzed the prison records and medical records of female psychiatric patients transferred to Hachioji Medical Prison between 2002 and 2011. Based on the offense listed at the time of sentencing, we extracted a shoplifting group and a drug-offense group from among all patients with eating disorders. One patient from the former group who had used substances and two from the latter group who had never shoplifted were excluded from the study. The groups had 41 and 14 patients, respectively. A control group comprised patients with other mental disorders (n = 34). We compared eating disorder histories and subtypes, weight changes, comorbidities, life histories, past behavioral problems, and clinical behavioral problems among the three groups.

RESULTS

The shoplifting group exhibited less impulsive behavior, substance abuse, antisocial features, borderline personality disorder, and past bulimia than did the drug-offense and control groups. The shoplifting group had higher educational achievement and steadier employment; however, their eating disorder histories and interpersonal dysfunction were more severe, and they had a higher psychiatric treatment dropout rate. There were also significant relationships with low body weight, anorexia nervosa-restricting type, obsessive-compulsive behaviors, and obsessive-compulsive personality disorder in the shoplifting group. During the clinical course, food refusal, excessive exercise, food hoarding, and falsification of dietary intake amounts were more frequently observed in the shoplifting group. Conversely, drug requests and occurrences of self-harm were less frequent in the shoplifting group than in the drug-offense group.

CONCLUSIONS

Although these results may be associated with specific characteristics of patients with eating disorders in the medical prison setting, we concluded that the repeated shoplifting by these patients is unrelated to antisocial or impulsive characteristics but is deeply rooted in these patients' severe and undertreated eating disorder psychopathology. Strong supportive treatment should be considered for patients with eating disorders who develop shoplifting behaviors. Further research is required to elucidate the mechanisms responsible for the relationship between shoplifting and eating disorders.

Defining Features of Unhealthy Exercise Associated with Disordered Eating and Eating Disorder Diagnoses

OBJECTIVES

The current study sought to compare different features of unhealthy exercise on associations with disordered eating and their ability to identify individuals with eating disorders. A secondary aim of the study was to compare prevalence and overlap of different aspects of unhealthy exercise and potential differences in their gender distribution.

DESIGN

Cross-sectional epidemiological study.

METHODS

A community-based sample of men (n=592) and women (n=1468) completed surveys of health and eating patterns, including questions regarding exercise habits and eating disorder symptoms.

RESULTS

Compulsive and compensatory features of exercise were the best predictors of disordered eating and eating disorder diagnoses compared to exercise that was excessive in quantity. Further, compulsive and compensatory aspects of unhealthy exercise represented overlapping, yet distinct qualities in both men and women.

CONCLUSIONS

Including the compulsive quality among the defining features of unhealthy exercise may improve identification of eating disorders, particularly in men. Results suggest that the compensatory aspect of unhealthy exercise is not adequately captured by the compulsive aspect of unhealthy exercise. Thus, interventions that target unhealthy exercise behaviors among high-risk individuals, such as athletes, may benefit from addressing both the compulsive and compensatory aspects of unhealthy exercise. Future prospective longitudinal studies will aid in determining the direction of the association between these features of unhealthy exercise and the onset of eating pathology.

The expression of excessive exercise co-segregates with the risk of developing an eating disorder in women

Excessive exercise (EE) is an important symptom of eating disorders (ED) and is a likely risk factor for developing ED, however, no population-based studies have been performed on the relationship between EE and obtaining ED diagnosis. The aim of this study was to examine the co-occurrence of EE and ED diagnosis in a general population of women. Data for 778 females (age min=30, max=55) from the Saint Thomas Twin Registry, London were used. Phenotypes analyzed included self-reported time spent on physical activity per week, ED diagnosis, Eating Disorder Inventory results (EDI-III), age, BMI and kinship (twin pair). Generalized Estimating Equation analysis showed that only EE (>5 h of exercise per week) and Bulimia Subscale of EDI-III were significantly associated with obtaining ED diagnosis throughout the life. These data revealed that the odds of ever being diagnosed with an ED are more than 2.5 times higher for excessive exercisers compared to individuals with lower activity levels. These data support the notion that EE may be an important risk factor for developing an ED in women.