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Hebebrand J, Plieger M, Milos G, Peters T, Hinney A, Antel J. Does hypoleptinemia trigger entrapment in anorexia nervosa? Etiological and clinical considerations. EUROPEAN EATING DISORDERS REVIEW 2024; 32:557-574. [PMID: 38303556 DOI: 10.1002/erv.3071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 11/08/2023] [Accepted: 01/13/2024] [Indexed: 02/03/2024]
Abstract
Based on the recent observation that human recombinant leptin (r-Met-hu-leptin; metreleptin) may induce a profound alleviation of the complex symptomatology of patients with anorexia nervosa (AN), we examine the implications for our conceptualisation of this eating disorder. Hypoleptinemia as a core endocrine feature of AN serves as a central and peripheral trigger of tissue-specific adaptations to starvation. In this narrative review, we argue that leptin deficiency may explain many of the puzzling features of this eating disorder. Weight loss can be viewed as a two-step process, with only the second step entailing hypoleptinemia and thereby the entrapment characteristic of AN. We discuss the central and peripheral distribution of leptin receptors and consider possible functional implications of hypoleptinemia. We contrast the slow psychological recovery of patients with AN and of people who experienced starvation upon weight recovery with the rapid onset of improvements upon off-label metreleptin treatment. Characteristics of the sex and age dependent secretion of leptin may contribute to the elevated vulnerability of young females to develop AN.
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Affiliation(s)
- Johannes Hebebrand
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Translational Neuro- and Behavioral Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | | | - Gabriella Milos
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Triinu Peters
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Translational Neuro- and Behavioral Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Anke Hinney
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Translational Neuro- and Behavioral Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Jochen Antel
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Centre for Translational Neuro- and Behavioral Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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Ramsay S, Allison K, Temples HS, Boccuto L, Sarasua SM. Inclusion of the severe and enduring anorexia nervosa phenotype in genetics research: a scoping review. J Eat Disord 2024; 12:53. [PMID: 38685102 PMCID: PMC11059621 DOI: 10.1186/s40337-024-01009-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 04/23/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Anorexia nervosa has one of the highest mortality rates of all mental illnesses. For those who survive, less than 70% fully recover, with many going on to develop a more severe and enduring phenotype. Research now suggests that genetics plays a role in the development and persistence of anorexia nervosa. Inclusion of participants with more severe and enduring illness in genetics studies of anorexia nervosa is critical. OBJECTIVE The primary goal of this review was to assess the inclusion of participants meeting the criteria for the severe enduring anorexia nervosa phenotype in genetics research by (1) identifying the most widely used defining criteria for severe enduring anorexia nervosa and (2) performing a review of the genetics literature to assess the inclusion of participants meeting the identified criteria. METHODS Searches of the genetics literature from 2012 to 2023 were performed in the PubMed, PsycINFO, and Web of Science databases. Publications were selected per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). The criteria used to define the severe and enduring anorexia nervosa phenotype were derived by how often they were used in the literature since 2017. The publications identified through the literature search were then assessed for inclusion of participants meeting these criteria. RESULTS most prevalent criteria used to define severe enduring anorexia nervosa in the literature were an illness duration of ≥ 7 years, lack of positive response to at least two previous evidence-based treatments, a body mass index meeting the Diagnostic and Statistical Manual of Mental Disorders-5 for extreme anorexia nervosa, and an assessment of psychological and/or behavioral severity indicating a significant impact on quality of life. There was a lack of consistent identification and inclusion of those meeting the criteria for severe enduring anorexia nervosa in the genetics literature. DISCUSSION This lack of consistent identification and inclusion of patients with severe enduring anorexia nervosa in genetics research has the potential to hamper the isolation of risk loci and the development of new, more effective treatment options for patients with anorexia nervosa.
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Affiliation(s)
- Sarah Ramsay
- Healthcare Genetics and Genomics Program, School of Nursing, Clemson University, Clemson, SC 29634, USA.
| | - Kendra Allison
- School of Nursing, Clemson University , Clemson, SC 29634, USA
| | - Heide S Temples
- School of Nursing, Clemson University , Clemson, SC 29634, USA
| | - Luigi Boccuto
- Healthcare Genetics and Genomics Program, School of Nursing, Clemson University, Clemson, SC 29634, USA
| | - Sara M Sarasua
- Healthcare Genetics and Genomics Program, School of Nursing, Clemson University, Clemson, SC 29634, USA
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Hemmingsen SD, Lichtenstein MB, Sjögren M, Gudex C, Larsen PV, Støving RK. Cognitive performance in hospitalized patients with severe or extreme anorexia nervosa. Eat Weight Disord 2023; 28:86. [PMID: 37864583 PMCID: PMC10590307 DOI: 10.1007/s40519-023-01585-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 06/29/2023] [Indexed: 10/23/2023] Open
Abstract
PURPOSE Severe malnourishment may reduce cognitive performance in anorexia nervosa (AN). We studied cognitive functioning during intensive nutritional and medical stabilization in patients with severe or extreme AN and investigated associations between weight gain and cognitive improvement. METHODS A few days after admission to a specialized hospital unit, 33 patients with severe or extreme AN, aged 16-42 years, completed assessments of memory, cognitive flexibility, processing speed, and attention. Mean hospitalization was 6 weeks. Patients completed the same assessments at discharge (n = 22) following somatic stabilization and follow-up up to 6 months after discharge (n = 18). RESULTS The patients displayed normal cognitive performance at admission compared to normative data. During nutritional stabilization, body weight increased (mean: 11.3%; range 2.6-22.2%) and memory, attention, and processing speed improved (p values: ≤ 0.0002). No relationship between weight gain and cognitive improvement was observed at discharge or follow-up. CONCLUSIONS Cognitive performance at hospital admission was normal in patients with severe or extreme AN and improved during treatment although without association to weight gain. Based on these results, which are in line with previous studies, patients with severe or extreme AN need not be excluded from cognitively demanding tasks, possibly including psychotherapy. As patients may have other symptoms that interfere with psychotherapy, future research could investigate cognitive functioning in everyday life in patients with severe AN. TRIAL REGISTRATION NUMBER The study is registered at clinicaltrials.gov (NCT02502617). LEVEL OF EVIDENCE Level III, cohort study.
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Affiliation(s)
- Simone Daugaard Hemmingsen
- Centre for Eating Disorders, Odense University Hospital, Odense, Denmark.
- Research Unit for Medical Endocrinology, Odense University Hospital, Odense, Denmark.
- Research Unit, Child and Adolescent Psychiatry, Mental Health Services in the Region of Southern Denmark, Odense, Denmark.
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
- Open Patient Data Explorative Network (OPEN), Odense, Denmark.
| | - Mia Beck Lichtenstein
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Centre for Digital Psychiatry, Region of Southern Denmark, Odense, Denmark
| | - Magnus Sjögren
- Institute for Clinical Science, Department of Psychiatry, Umeå University, Umeå, Sweden
| | - Claire Gudex
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient Data Explorative Network (OPEN), Odense, Denmark
| | - Pia Veldt Larsen
- Mental Health Services in the Region of Southern Denmark, Vejle, Denmark
| | - René Klinkby Støving
- Centre for Eating Disorders, Odense University Hospital, Odense, Denmark
- Research Unit for Medical Endocrinology, Odense University Hospital, Odense, Denmark
- Research Unit, Child and Adolescent Psychiatry, Mental Health Services in the Region of Southern Denmark, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient Data Explorative Network (OPEN), Odense, Denmark
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Hemmingsen SD, Daugaard N, Sjögren M, Lichtenstein MB, Gudex C, Piil F, Støving RK. Cognitive Flexibility in Hospitalized Patients with Severe or Extreme Anorexia Nervosa: A Case-Control Study. J Pers Med 2023; 13:1000. [PMID: 37373990 DOI: 10.3390/jpm13061000] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/08/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
OBJECTIVE To investigate whether cognitive inflexibility could be identified using the Wisconsin Card Sorting Test (WCST) in patients with severe and extreme anorexia nervosa (AN) compared to healthy control participants (HCs). METHOD We used the WCST to assess 34 patients with AN (mean age: 25.9 years, mean body mass index (BMI): 13.2 kg/m2) 3-7 days after admission to a specialized nutrition unit and 34 HCs. The Beck Depression Inventory II and the Eating Disorder Inventory 3 were distributed. RESULTS The patients displayed more perseveration than HCs controlled for age and years of education, with moderate effect sizes (perseverative responses (%): adjusted difference = -7.74, 95% CI: -14.29-(-1.20), p-value: 0.021; perseverative errors (%): adjusted difference = -6.01, 95% CI: -11.06-(-0.96), p-value: 0.020). There were no significant relationships between perseveration and depression, eating disorder symptoms, illness duration, or BMI. DISCUSSION Patients with severe and extreme AN demonstrated lower cognitive flexibility compared to HCs. Performance was not related to psychopathology or BMI. Patients with severe and extreme anorexia nervosa may not differ from less severe patients in cognitive flexibility performance. As this study exclusively focused on patients suffering from severe and extreme AN, potential correlations might be masked by a floor effect.
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Affiliation(s)
- Simone Daugaard Hemmingsen
- Centre for Eating Disorders, Odense University Hospital, 5000 Odense, Denmark
- Research Unit for Medical Endocrinology, Odense University Hospital, 5000 Odense, Denmark
- Research Unit, Child and Adolescent Psychiatry, Mental Health Services in the Region of Southern Denmark, 5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
- Open Patient Data Explorative Network (OPEN), 5000 Odense, Denmark
| | - Nicolaj Daugaard
- Department of Molecular Medicine, University of Southern Denmark, 5000 Odense, Denmark
| | - Magnus Sjögren
- Institute for Clinical Science, Department of Psychiatry, Umeå University, 901 87 Umeå, Sweden
| | - Mia Beck Lichtenstein
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
- Centre for Digital Psychiatry, Region of Southern Denmark, 5000 Odense, Denmark
| | - Claire Gudex
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
- Open Patient Data Explorative Network (OPEN), 5000 Odense, Denmark
| | - Frederikke Piil
- Centre for Eating Disorders, Odense University Hospital, 5000 Odense, Denmark
- Research Unit for Medical Endocrinology, Odense University Hospital, 5000 Odense, Denmark
- Research Unit, Child and Adolescent Psychiatry, Mental Health Services in the Region of Southern Denmark, 5000 Odense, Denmark
| | - René Klinkby Støving
- Centre for Eating Disorders, Odense University Hospital, 5000 Odense, Denmark
- Research Unit for Medical Endocrinology, Odense University Hospital, 5000 Odense, Denmark
- Research Unit, Child and Adolescent Psychiatry, Mental Health Services in the Region of Southern Denmark, 5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
- Open Patient Data Explorative Network (OPEN), 5000 Odense, Denmark
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Mehler PS, Anderson K, Bauschka M, Cost J, Farooq A. Emergency room presentations of people with anorexia nervosa. J Eat Disord 2023; 11:16. [PMID: 36759897 PMCID: PMC9909152 DOI: 10.1186/s40337-023-00742-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/27/2023] [Indexed: 02/11/2023] Open
Abstract
People with anorexia nervosa (AN) tend to shy away from engaging in typical primary care provider relationships in order to avoid detection. Therefore, they may seek care for their medical concerns through a local emergency department (ED). Inherently, AN is associated with a litany of medical complications, which become more prevalent as the severity of their eating disorder increases. Notwithstanding the typical young age at the onset of AN, no body system is immune to these medical complications. Thus, ED providers may need to pursue a medical diagnosis in order to explain presenting symptoms in people with AN. In addition to the medical issues, AN is also a serious mental illness with high mortality rates, including deaths by suicide. Therefore, ED providers also need to be familiar with relevant mental health issues for these people.
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Affiliation(s)
- Philip S Mehler
- ACUTE Center for Eating Disorders at Denver Health, Denver, CO, USA. .,University of Colorado School of Medicine, Denver, CO, USA.
| | - Kristin Anderson
- ACUTE Center for Eating Disorders at Denver Health, Denver, CO, USA.,University of Colorado School of Medicine, Denver, CO, USA
| | - Maryrose Bauschka
- ACUTE Center for Eating Disorders at Denver Health, Denver, CO, USA.,University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jeana Cost
- ACUTE Center for Eating Disorders at Denver Health, Denver, CO, USA.,Eating Recovery Center, Denver, CO, USA
| | - Asma Farooq
- ACUTE Center for Eating Disorders at Denver Health, Denver, CO, USA.,University of Utah School of Medicine, Salt Lake City, UT, USA
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Nagy H, Paul T, Jain E, Loh H, Kazmi SH, Dua R, Rodriguez R, Naqvi SAA, U. MC, Bidika E. A Clinical Overview of Anorexia Nervosa and Overcoming Treatment Resistance. Avicenna J Med 2022; 13:3-14. [PMID: 36969350 PMCID: PMC10038755 DOI: 10.1055/s-0042-1758859] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
AbstractAnorexia nervosa (AN) is a type of eating disorder that has been increasing in incidence and has been encountered more commonly by physicians in their daily practice. Both environmental and genetic risk factors paired along with a more susceptible neurobiology are at play in the emerging resistance to treatment in AN. Preoccupations with intense fear of weight gain, dietary restrictions, excessive exercise, and how the individual is perceived by society mixed with underlying psychopathology all further add to the issue. Many patients who fall into this cycle of obsessive and restrictive patterns refuse to get treatment. As clinicians, it is essential we recognize the early signs of both eating disorders during the initial primary care appointments.To review the literature on the etiology of AN, possible misdiagnosis leading to inappropriate management of this condition, and understand the treatment-resistant AN and its management. Additionally, it will explore possible reasons that contribute to the resistance to treatment, the underlying psychopathology of anorexics, its genetic predisposition, psychiatric comorbidities, identification of the early signs and symptoms, and timely prevention.Early recognition by a physician includes a thorough history and physical examination, pertinent laboratory, and electrolyte studies, and identifying comorbid psychiatric conditions. The treatment of AN is intricate and requires a holistic approach. Treatment includes multiple modalities such as nutritional rehabilitation and psychosocial and pharmacological therapies. An interdisciplinary team of medical professionals for managing chronic AN is recommended.
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Affiliation(s)
- Hassan Nagy
- Division of Research & Academic Affairs, Larkin Health System, South, Miami, Florida, United States
| | - Tanya Paul
- Division of Research & Academic Affairs, Larkin Health System, South, Miami, Florida, United States
| | - Esha Jain
- Division of Research & Academic Affairs, Larkin Health System, South, Miami, Florida, United States
| | - Hanyou Loh
- Division of Research & Academic Affairs, Larkin Health System, South, Miami, Florida, United States
| | - Syeda Hafsa Kazmi
- Division of Research & Academic Affairs, Larkin Health System, South, Miami, Florida, United States
| | - Rishbha Dua
- Division of Research & Academic Affairs, Larkin Health System, South, Miami, Florida, United States
| | - Ricardo Rodriguez
- Division of Research & Academic Affairs, Larkin Health System, South, Miami, Florida, United States
| | - Syed Ali Abbas Naqvi
- Division of Research & Academic Affairs, Larkin Health System, South, Miami, Florida, United States
| | - Metu Chiamaka U.
- Division of Research & Academic Affairs, Larkin Health System, South, Miami, Florida, United States
| | - Erjola Bidika
- Division of Research & Academic Affairs, Larkin Health System, South, Miami, Florida, United States
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Guarda AS, Hanson A, Mehler P, Westmoreland P. Terminal anorexia nervosa is a dangerous term: it cannot, and should not, be defined. J Eat Disord 2022; 10:79. [PMID: 35672780 PMCID: PMC9175496 DOI: 10.1186/s40337-022-00599-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 05/23/2022] [Indexed: 12/04/2022] Open
Abstract
A recent article (JED 10:23, 2022) proposed defining terminal anorexia to improve access to palliative and hospice care, and to medical aid in dying for a minority of patients with severe and enduring anorexia nervosa (SE-AN). The authors presented three cases and, for two, the first author participated in their death. Anorexia nervosa is a treatable psychiatric condition for which recovery may be uncertain. We are greatly concerned however regarding implications of applying the label "terminal" to anorexia nervosa and the risk it will lead to unjustified deaths in individuals whose mental illness impairs their capacity to make a reasoned treatment decision.
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Affiliation(s)
- Angela S Guarda
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, 21287, USA.
| | - Annette Hanson
- Department of Psychiatry, University of Maryland, Jessup, MD, 20794, USA
| | - Philip Mehler
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Patricia Westmoreland
- Department of Psychiatry, University of Colorado Anschutz Medical Center, Aurora, CO, 80045, USA
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Stedal K, Scherer R, Touyz S, Hay P, Broomfield C. Research Review: Neuropsychological functioning in young anorexia nervosa: A meta-analysis. J Child Psychol Psychiatry 2022; 63:616-625. [PMID: 34970745 DOI: 10.1111/jcpp.13562] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/26/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Cognitive inflexibility and compulsive behaviours are commonly observed in patients with anorexia nervosa (AN) and are often considered to be caused by impairments in executive functioning and visuospatial processing. Despite an increasing number of young individuals presenting with AN, there is a lack of meta-analytic evidence on the neuropsychological functioning in this population. Our primary aim was to review and synthesize the differences in neuropsychological test performance between young people with AN and healthy controls, and to explore potential moderators. METHODS A database search following PRISMA guidelines of MEDLINE, PsycINFO, ISI Web of Science and Epistemonikos was conducted. Hedges' g served as an effect size indicating the standardized mean differences. We utilized mixed-effects meta-regression and machine learning meta-analyses to identify relevant moderators. RESULTS Sixteen studies met the inclusion criteria with a total of 1333 participants (665 with AN) and 59 effect sizes. Random-effects meta-analyses demonstrated a small and insignificant difference between young individuals with AN and controls ( g¯ = -0.144, 95% CI [-0.328, 0.041]) in overall neuropsychological functioning. However, the difference was significant for the cognitive domains of memory, working memory and visuospatial abilities. Moderator and machine-learning analyses revealed a stronger negative effect in older participants and moderator effects of country and assessment quality. CONCLUSIONS Our findings highlight the significant impact of age on neuropsychological test performance in patients with AN. There is a need for a more widespread inclusion of potentially confounding variables in primary studies as well as instruments specifically targeted at younger populations.
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Affiliation(s)
- Kristin Stedal
- Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital Oslo Ullevål, Oslo, Norway
| | - Ronny Scherer
- Faculty of Educational Sciences, Centre for Educational Measurement at the University of Oslo (CEMO), University of Oslo, Oslo, Norway
| | - Stephen Touyz
- School of Psychology, Faculty of Science, The University of Sydney, Sydney, NSW, Australia
| | - Phillipa Hay
- Translational Health Research Institute, Western Sydney University, Penrith, NSW, Australia
| | - Catherine Broomfield
- School of Psychology, Faculty of Science, The University of Sydney, Sydney, NSW, Australia
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