Chapter 13: Anorexia Nervosa

James Lock

Nina Kirz

Overview

Features of Anorexia Nervosa (AN):Behavioral

• 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 criteriaResearch suggests no difference in severity of illness

between patients with and without amenorrheaMay allow more adolescents to receive diagnosis of AN,

rather than unspecified diagnosisVerbalization of fear of weight gain no longer

necessaryResearch 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

ANOREXIA NERVOSA

A. 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 criteriaResearch suggests no difference in severity of illness

between patients with and without amenorrheaMay allow more adolescents to receive diagnosis of AN,

rather than unspecified diagnosisVerbalization of fear of weight gain no longer

necessaryResearch 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% 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 diagnosedBimodal age of onset in females, ~14 and ~18 years of

ageSimilar rates across ethnic and socioeconomic lines

Debate as to whether incidence is increasing

Neurobiological Dysfunction

SerotoninMost 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 metabolitesSpecific abnormalities have not yet been identified

DopamineRecent interest given its role in reward systemsSuggest that hypersensitivity of dopaminergic system

may account for some of AN pathology

Neurobiological Dysfunction, cont

NeuroimagingPositron 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

NeurocognitiveProblems 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 riskRecent data suggests that genetic factors account for >

50% of the heritable riskSpecific genetic mechanism unknown

Behavioral Dysfunction

Behavioral course of illnessOften starts with the desire to lose a little weightWeight 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 distortionPatient may recognize his/her overall thinness, but still

believe a part or parts of the body are grossly overweightThinness is critical to self-worth

Denial and deceptionPatients often have mixed feelings about recoveryDisordered behaviors often kept secret and denied

PerfectionismDrive and perfectionism lead to all-or-nothing thinkingFailure to achieve perfection often leads to low self-

esteem and low self-efficacy

Emotional Dysfunction

Anxiety and depressionSymptoms of anxiety and depression common and may

be a direct effect of starvationEating disordered behaviors may lead to social isolation

and withdrawal, which contributes to anxiety/depressionPremorbid anxiety disorders common in patients with ANAnxious and depressive symptoms may resolve with

weight restoration

Medical Complications in AN

AN has highest mortality rate of any psychiatric disorderMortality rate is 5.6% per decade of illness

Complications include:Growth retardationPubetal delayOsteoporosisStructural abnormalities of the brainCardiac dysfunctionElectrolyte inbalanceBleeding in stomach/esophagus

Sociocultural Factors

Social pressures to be thin may contribute to development of AN, but are not the sole causeRates of AN are highest after periods when beauty ideal

for women is thinNon-Western cultures and cultures that value plumpness

have lower rates of ANExtreme 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 onsetAN 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 studiesYields 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 reliabilityChild 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 treatmentMorgan-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 therapyFor 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 therapiesIndividual 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

CBTModified 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/weightMay be more useful for relapse prevention, after weight

restorationCBT-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 treatmentMay be used in more severe casesApproaches based on behavioral principles to restore

weightLimited data suggests they are effective in promoting

recovery, but are costly

Intervention With Medication

PsychopharmacologicA variety of medications have been tried, but none

appear to be systematically usefulSome data suggests fluoxetine may be useful in relapse

preventionOther studies have evaluated antipsychotic medications,

with mixed results

Treatment Recommendations

No consensus as to the best treatment approachIn adolescents, FBT is the clear first-line treatmentTreatment 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 ANDevelop 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