Class 21 (Eating disorders: anorexia nervosa)

historical example of food restriction - Miraculous Maids

medieval practice where young women seriously restricted food intake (sometimes to the point of death) as part of a larger practice of piety, devotion, and ascetism

• Saint Catherine of Siena ate nothing but a bit of herbs per day, and would purge or do other compensatory behaviors if forced to eat

• parallels with anorexia nervosa

core features of all eating disorders

• over- or under- control of eating behaviors

• self-esteem tied to physical appearance

• difficulties with interoceptive awareness

distinction between anorexia and other eating disorders

anorexia

• symptoms associated with pride

• unusually low body weight

• recurrent binge/purge in the last 3 months

vs

bulimia nervosa and BED

• symptoms associated with shame

• not unusually low body weight

• binge/compensatory behaviors weekly for the past 3 months

diagnostic criteria of anorexia nervosa

Restriction of energy intake (food) relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health

• significantly low weight = weight that is less than minimally normal (for children/adol: less gain than minimally expected)

Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes iwth weight gain, even though at a significantly low weight

Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight

two subtypes of anorexia nervosa

1. binge eating/purging type

2. restricting type

binge eating/purging type

during the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e. self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

restricting type

during the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior (i.e. self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.

binging and purging can occur in _____

both anorexia and bulimia (a lot of ppl forget it’s a subtype of anorexia)

according to the DSM, differences between anorexia b/p subtype and bulimia primarily lie in _____

the weight of the individual and the frequency of the binge/purge

prevalence of anorexia nervosa

1% or less, relatively uncommon

mortality of anorexia

bc the lack of nutrients can affect organs (especially the heart), mortality rates of anorexia are very high (5-15%)

• anorexia is considered to have the highest mortality rate of any clinical disorder

biological basis of anorexia

anorexics tend to have very dysregulated levels of metabolites or serotonin and dopamine in their cerebrospinal fluid

• SSRIs began to be used as a treatment for anorexia nervosa

• serotonin has loads of functions but one role of serotonin is to regulate how much we eat and whether we feel full/hungry

genes and anorexia

no great sense of which genes are involved in anorexia

• but one that seems to be is 5HT1A receptor (gene that regulates levels of serotonin)

treatment and relapse for anorexia nervosa

ppl with histories of anorexia have very high rates of relapse

• about 1/3 of ppl whose symptoms remit relapse within 6 months of treatment

• about 50% relapse overall (but this is related to type of treatment)

what happens even after eating patterns stabilize (behavioral change) for those with anorexia?

ppl with histories of anorexia tend to maintain severely disordered cognitions about food, weight (thinking component)

if anorexia is related to neurochemistry and a treatment is truly effective, we would want to see both _____

behavioral change and biological change

do we see biological change for anorexia patients going through treatment?

unfortunately no

• individuals with anorexia often continue to show abnormal levels of CSF metabolites of dopamine and serotonin even after participation in a “successful” treatment study, with fully stabilized weight and eating

• ^^ might partly explain the high rate of relapse and high persistence of disordered cognitions

personality traits and anorexia

low serotonin has been correlated with the sorts of personality traits which are associated with anorexia

• perfectionism, guilt, preference for order

• these traits are also common in individuals with anxiety disorders

hypothesis about anorexia nervosa

for some ppl, anorexia nervosa is (at its core) an anxiety disorder

• societal emphasis on the thin body ideal combined with pubertal weight gain which, in many cases, leads girls to channel their anxiety into restrictive eating

developmental support for this hypothesis

around 70% of ppl with anorexia have lifetime histories of anxiety disorders

• most commonly: social phobia, separation anxiety disorder, specific phobia, generalized anxiety disorder

in about 2/3 of cases, these anxiety disorders precede the onset of anorexia

anxiety disorders or significant anxiety symptoms also persist after anorexia symptoms are stabilized

a possible trajectory for anxiety with anorexia

childhood anxiety disorder

↓

puberty (childhood anxiety + weight gain, changes in gender roles and social enviro = anorexia and comorbid anxiety disorder)

↓

treatment for anorexia might stabilize weight but anxiety disorder persists

reading recap: what conclusions does LeGrange draw about the family’s role in anorexia?

family patterns do not “cause” anorexia, nor are certain types of families more consistently associated with ED

• involving the family in treatment is preferred, except in cases of extreme parental psychopathology

impact of diet culture and social influences on anorexia

being surrounded by diet culture, no matter if it comes from your family or peers or community, is a contributor to the development of anorexia

reading recap: Harriet Brown’s story - Kitty

similar to the Miraculous Maids case

• feelings of feailure surrounding eating

• intense exercise

• couldn’t stop thinking about food

• persistent refusal to eat

• evaluating calories in everything

• experiences physical consequences of starvation

• typical age of onset (13yo)

• perfectionism

parents were very involved in the treatment process

reading recap: what is the core feature of the Maudsley System for treating eating disorders?

parents are in charge of “refeeding” their child

reading recap: how is the Maudsley System’s parental refeeding approach unusual compared to other ideas for treating anorexia?

Maudsley System views the family as the best chance an anorexic has for recovery

• historically, families were viewed as causing anorexia so treatments usually involved “parentectomy”, or getting rid of the parent factor

how well does the Maudsley System work?

• it’s good for adolescents: about 2x as many teens who participate in Maudsley treatment show full symptom remission at the end of treatment compared to teens in individual treatment

• gains maintained at 1 year follow up

• Maudsley also improves comorbid conditions, including panic disorder and other anxiety disorders, even though that’s not the focus of treatment

• BUT even the Maudsley program is associated with only approx 40% full remission in many studies

Maudsley is still a new-ish treatment

the published treatment protocol (family based treatment for adolescent anorexia nervosa) is formally not yet 20 years old

• 8 RCTs to date

  • while full remission is not the norm, partial remission and symptom improvement is about 75%

• studies have shown not just how well Maudsley works or doesn’t work, but more about when adaptations might need to be made to make it “work better”

• some families simply need more time for the treatment, especially divorced or single parents

are there alternatives to Maudsley?

not many, but promising early results from RCT on Reduced Environmental Stimulation Therapy (REST)

REST

participants float in a shallow, warm pool filled with Epsom Salt for approx 1 hr, often in darkness, with air and water temperature set to match body temp

goal: minimize external feedback (sounds, sights, etc) so that interoceptive signals become more obvious

interoception

awareness or perception of the body's internal states, including physiological signals like heart rate, hunger, and pain

RCT of REST for anorexia nervosa (Choquette et al 2023)

8 sessions of REST scheduled during break times during treatment day, REST vs care as usual group

• less body dissatisfaction for REST group (smallish effect)

• much less state anxiety for REST group (calming)

• not an enormous amount of change and there’s kind of a return to baseline between sessions... but each sessions is associated with trait changes in how participants feel