1. Chapter 13: Anorexia Nervosa
James Lock
Nina Kirz

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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)

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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