Chapter 13: Anorexia Nervosa James Lock Nina Kirz

Overview Features of Anorexia Nervosa (AN): Behavioral Psychological Refusal to maintain an acceptable weight Restrictive eating, excessive exercise, and purging in some Psychological Intense fear of fat or weight gain Body image distortion Physiological Malnutrition-related complications, for example osteoporosis, lanugo, amenorrhea, hair loss

Significant Changes for Anorexia Nervosa in DSM-5 Elimination of the amenorrhea criteria Research suggests no difference in severity of illness between patients with and without amenorrhea May allow more adolescents to receive diagnosis of AN, rather than unspecified diagnosis Verbalization of fear of weight gain no longer necessary Research suggests no difference between those individuals who express fear of weight gain versus those who do not Indicates change from DSM-IV-TR criteria

DSM-5 Diagnostic Criteria for Anorexia Nervosa Restriction of energy intake below what is necessary to maintain a healthy weight B. Intense fear of fat, as evidenced by verbalizations or behaviors that interfere with the maintenance of a healthy weight C. Body image disturbance, undue influence of body shape/weight on self-evaluation, or persistent denial of the seriousness of low weight Two subtypes: Restricting subtype: weight loss is accomplished exclusively through caloric restriction (i.e. dieting, fasting) and/or excessive exercise; the individual has not binged or purged in the last 3 months Binge-eating/purging subtype: the individual has binged (subjective or objective binge episodes) or purged in the last 3 months Indicates change from DSM-IV-TR criteria

Rationale for Changes Elimination of the amenorrhea criteria Research suggests no difference in severity of illness between patients with and without amenorrhea May allow more adolescents to receive diagnosis of AN, rather than unspecified diagnosis Verbalization of fear of weight gain no longer necessary Research suggests no difference between those individuals who express fear of weight gain versus those who do not

History of Anorexia Nervosa Lasègue (1873) and Gull (1873) both described an illness affecting girls and young women characterized by severe weight loss, labeled anorexia hystérique and anorexia nervosa Simmonds (1914) found lesions in the pituitaries of emaciated patients, speculated that AN had an endocrine etiology Bruch (1973, 1978) conceptualized AN in terms of low self-esteem and body distortion Minuchin et al (1978) and Palazzoli (1974) view AN as an expression of family psychopathology

Epidemiology Prevalence of AN ~0.1% to 0.9% Demographics Rates of subthreshold AN higher Demographics ~5% to 10% of patients male, although true incidence may be higher as males are less likely to be diagnosed Bimodal age of onset in females, ~14 and ~18 years of age Similar rates across ethnic and socioeconomic lines Debate as to whether incidence is increasing

Neurobiological Dysfunction Serotonin Most popular neurotransmitter in AN research, given its involvement in mood, obsessions, appetite regulation, and impulse control Patients with AN have low levels of 5-HT metabolites Specific abnormalities have not yet been identified Dopamine Recent interest given its role in reward systems Suggest that hypersensitivity of dopaminergic system may account for some of AN pathology

Neurobiological Dysfunction, cont Neuroimaging Positron emission tomography (PET) and single-photon emission computed tomography (SPECT) studies show regional differences in patients with AN compared to controls Functional magnetic resonance imaging (fMRI) studies show differential activation in response to food stimuli in patients with AN compared to controls Many studies find decreased brain mass and enlarged sulci in acute phase of illness No consensus as to whether these changes can be reversed with refeeding

Neurobiological Dysfunction, continued Neurocognitive Problems with attention, executive functioning, working memory, response inhibition, and mental flexibility in patients with AN Deficits likely involved in etiology and maintenance of the disorder, and may be obstacles to successful treatment Genetic risk Recent data suggests that genetic factors account for > 50% of the heritable risk Specific genetic mechanism unknown

Behavioral Dysfunction Behavioral course of illness Often starts with the desire to lose a little weight Weight loss gradually spirals out of control, perhaps due to: Restricted intake Avoidance of certain foods Elimination of certain meals Excessive and compulsive exercise (e.g., exercise anorexia) Purging behaviors and/or binge eating (in patients with binge/purge subtype of AN) Patients in acute phase of illness typically extremely preoccupied with food and eating

Cognitive Dysfunction Body image distortion Patient may recognize his/her overall thinness, but still believe a part or parts of the body are grossly overweight Thinness is critical to self-worth Denial and deception Patients often have mixed feelings about recovery Disordered behaviors often kept secret and denied Perfectionism Drive and perfectionism lead to all-or-nothing thinking Failure to achieve perfection often leads to low self-esteem and low self-efficacy

Emotional Dysfunction Anxiety and depression Symptoms of anxiety and depression common and may be a direct effect of starvation Eating disordered behaviors may lead to social isolation and withdrawal, which contributes to anxiety/depression Premorbid anxiety disorders common in patients with AN Anxious and depressive symptoms may resolve with weight restoration

Medical Complications in AN AN has highest mortality rate of any psychiatric disorder Mortality rate is 5.6% per decade of illness Complications include: Growth retardation Pubetal delay Osteoporosis Structural abnormalities of the brain Cardiac dysfunction Electrolyte inbalance Bleeding in stomach/esophagus

Sociocultural Factors Social pressures to be thin may contribute to development of AN, but are not the sole cause Rates of AN are highest after periods when beauty ideal for women is thin Non-Western cultures and cultures that value plumpness have lower rates of AN Extreme weight loss as in AN likely the product of an interaction between overvaluation of thin ideal and personality traits (e.g., perfectionism, obsessiveness, emotional suppression)

Sociocultural Factors, cont Triggers for symptom onset AN a response to pubetal changes in some individuals Disordered behaviors and extreme weight loss return affected individuals to preadolescent state and delay the developmental challenges of adolescence Symptoms may be triggered by external stressors For example loss, move, abuse, or being teased about weight Familial attitudes about food, dieting, and appearance may be relevant Acceptance of thin ideal and normalizing of dieting behavior may be transmitted to children Unclear whether familial problems are the cause or effect of AN

Assessment: Structured Interviews Eating Disorder Examination (EDE) Most commonly used measure in treatment studies Yields categorical data for DSM-IV diagnosis, continuous data on four subscales (restraint, eating concern, shape concern, and weight concern) and behavioral data on frequency of binge eating and purging behaviors Requires intense training to achieve reliability Child version (ChEDE) also available Schedule for Affective Disorders and Schizophrenia for School-Aged Children (K-SADS) Yields diagnostic information but not sufficiently detailed to assess response to treatment Morgan-Russell Battery Assesses nutritional status, menstrual function, mental state, sexual adjustment, and socioeconomic status over preceding 6 months Used in outcome research, but poor interrater reliability

Assessment: Self-Report Measures Questionnaire version of EDE (EDE-Q) Assesses same domains as interview version with good reliability Eating Attitudes Test (EAT) Assesses food preoccupation, thin body image, vomiting/laxative abuse, dieting, slow eating, clandestine eating, and perceived social pressure to gain weight Eating Disorders Inventory (EDI) Assesses drive for thinness, bulimia, body dissatisfaction, ineffectiveness, perfectionism, interpersonal distrust, interoceptive awareness, maturity fears, asceticism, impulse regulation, and social insecurity Effective as screening measure and measure of symptom severity and change, not able to differentiate between eating disorder diagnoses

Intervention Outpatient therapy For adolescents, family therapy is superior In family-based treatment (FBT), parents are empowered and taught to restore child’s weight at home Shown to be effective in treatment of adolescents with AN and BN Data in adults is hard to interpret, due to small sample sizes and high drop-out rates No clear treatment of choice Cognitive behavioral therapy (CBT) for relapse and specialist individual therapy have shown some promise

Intervention, cont Individual therapies Individual psychodynamic therapy for AN: Addresses maturational issues associated with puberty/adolescence Ego-oriented individual therapy (EOIT): Corrects deficits in self-concept and individuation process Specialist supportive individual therapy (SSIT): Utilizes a supportive therapeutic relationship to effect behavioral change Interpersonal therapy (IPT) not as promising as for other eating disorders

Intervention, cont CBT CBT-enhanced (CBT-E) Modified from CBT for depression to treat symptoms of AN, including ego-syntonic nature, influence of physiological symptoms on psychological functioning, distorted beliefs about food/weight, and low self-esteem Goal is to move concerns away from food/eating/weight May be more useful for relapse prevention, after weight restoration CBT-enhanced (CBT-E) New modification of CBT, includes modules that address problems of eating disordered patients that interfere with progress (e.g., perfectionism, interpersonal problems) Preliminary data is promising

Intervention, cont Inpatient, day-hospital, and residential treatment May be used in more severe cases Approaches based on behavioral principles to restore weight Limited data suggests they are effective in promoting recovery, but are costly

Intervention With Medication Psychopharmacologic A variety of medications have been tried, but none appear to be systematically useful Some data suggests fluoxetine may be useful in relapse prevention Other studies have evaluated antipsychotic medications, with mixed results

Treatment Recommendations No consensus as to the best treatment approach In adolescents, FBT is the clear first-line treatment Treatment of adults less clear, largely due to high drop-out rates Adults with AN generally more treatment resistant than adolescents with AN or adults with other eating disorders Future directions in AN treatment research: Compare FBT to other treatments for adolescents with AN Develop and study new treatments for adults, for example couples therapy based on FBT principles, therapy to address emotional avoidance in AN, and cognitive remediation therapy