Anorexia Nervosa Dampens Subjective and Facial Pain Responsiveness

Regional cerebral blood flow changes associated with interoceptive awareness in the recovery process of anorexia nervosa

Existing treatments for adults with anorexia nervosa (AN) have limited proven efficacy. New treatments that have been suggested involve targeted, brain-directed interventions such as transcranial direct current stimulation (tDCS). We describe findings from seven individuals with treatment-resistant AN who received 10 sessions of anodal tDCS, over the left dorsolateral prefrontal cortex (DLPFC). In this open-label, single-arm study, seven patients received anodal tDCS (2mA) for 25 minutes over the left dorsolateral prefrontal cortex daily for ten days. Assessments pre-tDCS, post-tDCS and one month later included the Eating Attitude Test (EAT), Eating Disorder Inventory (EDI) and Beck Depression Inventory (BDI). Three patients improved in all three rating scales immediately after the treatment sessions and one month later. Two patients showed improvement at the end of treatment but returned to the baseline after one month. One subject improved only on the BDI scale but not eating scales. The scores in the three rating scales were unaffected by treatment in the remaining patient. There was a significant effect of time (pre, post and 1 month later) on the three rating scores; BDI (P = 0.016), EDI (P = 0.018) and EAT (P = 0.016) and a significant correlation between the percent improvement of BDI and EAT (p = 0.01), and between BDI and EDI (P = 0.006). These findings suggest that tDCS has potential as an adjuvant treatment for AN and deserves further study.

Introduction: Mental disorders that are associated with severe disturbances in eating behavior are called “eating disorders.” According to the American Psychiatric Association1, a mental disorder consists of “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.” Of particular attention here is the eating disorder of anorexia nervosa. This disorder amounts to a refusal to maintain a normal body weight. In the fourth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV, pp. 544–545), the diagnostic criteria for anorexia nervosa (See Table 1) are associated with physical symptoms (abnormal body weight, amenorrhea) and psychological symptoms (fear in gaining weight and body image disturbances).Table 1: A. Diagnostic Criteria for Anorexia NervosaDiscussion: Although the incidence of clinically diagnosed anorexia nervosa is only about 1% in the U.S. population, its prevalence among athletes in sports that emphasize leanness has been estimated to be much higher. Part of this confusion comes from misinterpreting scores on questionnaires such as the Eating Disorders Inventory (EDI) or the Eating Attitudes Test (EAT). These standardized instruments are not designed to determine psychopathology since it takes a clinical interview to determine if the DSM-IV diagnostic criteria are met. Instead, the EDI and EAT are useful in determining who might be at risk for meeting the diagnostic criteria of anorexia nervosa. Athletes in sports that emphasize leanness will often have elevated scores on the drive for thinness scale of the EDI2. However, when athletes are subjected to a clinical interview, most of those classified as “at risk,” are not found to have a true clinical relevant “eating disorder.” Higher scores on the EDI, for instance, may be only be a rationale response on the part of the athlete and may not represent a clinical eating disorder. As O'Connor and Smith3 have pointed out, a higher drive for thinness score may merely represent a desire to perform well, especially in light of the time the athlete has devoted to the sport. Evidence from several sources suggests that athletes are more apt to have “subclinical or disordered eating patterns,” particularly when their sports are in-season. However, the disordered eating patterns seen in most athletes are not of the severity that would qualify as a clinically diagnosed eating disorder.

Anorexia nervosa in male adolescents: Body image, eating attitudes and psychological traits

Facial expression may be a surrogate marker of pain in Alzheimer disease (AD) when self-report of pain is compromised. Recent studies have demonstrated increased pain sensitivity in AD; however, experimental pain studies analyzing facial expressions in AD are limited and report inconsistent results. The aims of this study were to examine facial expression of pain in AD patients and its relationship to sum-scored measures of multiple pain behavioral domains and subjective pain ratings. The Facial Action Coding System (FACS) was used to characterize facial expressions in 35 AD patients and 33 healthy seniors during pressure algometry. To improve pain specificity, facial responses were categorized as pain-relevant or pain-irrelevant before group analyses. We also assessed the relationship of AD severity to differential facial responsiveness by correlating FACS-based results with clinical pain scales (portions of the Pain Assessment in Advanced Dementia scale and the Faces Pain Scale-Revised [FPS-R]). No significant relationship was found between AD severity and FACS scores. Pain-relevant, but not irrelevant, FACS scores were increased in AD patients compared with seniors without AD. Pain Assessment in Advanced Dementia scale stimulus-response slopes were correlated with those of pain-relevant FACS and FPS-R in both the groups. Pain-relevant FACS slopes showed no relationship with those of the FPS-R in either group. Pain sensitivity is increased across all severities of AD when measured using the FACS. Clinical observational pain scales support the relevance of facial expression as a partial compensatory pain communication modality for AD. However, measures of pain behavior that sum across objective coding of several domains provide a better indicator of subjective pain than measures of facial expression alone.

Évaluation des préoccupations corporelles dans les troubles des conduites alimentaires par le Body Shape Questionnaire

Exercise and eating disorders: A 3-year inpatient hospital record analysis

Immersive virtual reality (VR) is a novel form of distraction analgesia, yet its effects on pain-related brain activity when used adjunctively with opioid analgesics are unknown. We used subjective pain ratings and functional magnetic resonance imaging to measure pain and pain-related brain activity in subjects receiving opioid and/or VR distraction. Healthy subjects (n = 9) received thermal pain stimulation and were exposed to four intervention conditions in a within-subjects design: (a) control (no analgesia), (b) opioid administration [hydromorphone (4 ng/mL target plasma level)], (c) immersive VR distraction, and (d) combined opioid + VR. Outcomes included subjective pain reports (0-10 labeled graphic rating scales) and blood oxygen level-dependent assessments of brain activity in five specific, pain-related regions of interest. Opioid alone significantly reduced subjective pain unpleasantness ratings (P < 0.05) and significantly reduced pain-related brain activity in the insula (P < 0.05) and thalamus (P < 0.05). VR alone significantly reduced both worst pain (P < 0.01) and pain unpleasantness (P < 0.01) and significantly reduced pain-related brain activity in the insula (P < 0.05), thalamus (P < 0.05), and SS2 (P < 0.05). Combined opioid + VR reduced pain reports more effectively than did opioid alone on all subjective pain measures (P < 0.01). Patterns of pain-related blood oxygen level-dependent activity were consistent with subjective analgesic reports. These subjective pain reports and objective functional magnetic resonance imaging results demonstrate converging evidence for the analgesic efficacy of opioid administration alone and VR distraction alone. Furthermore, patterns of pain-related brain activity support the significant subjective analgesic effects of VR distraction when used as an adjunct to opioid analgesia. These results provide preliminary data to support the clinical use of multimodal (e.g., combined pharmacologic and nonpharmacologic) analgesic techniques.

Altered cortical excitability in anorexia nervosa

Recent case reports have led to speculation that eating disorders (anorexia nervosa(AN), bulimia(B), & their partial syndromes) may occur with increased frequency in association with diabetes(IDDM) & that these disorders may contribute to poor glycemic control. We report preliminary results of a systematic study of adolescent females with IDDM, since this is the age group of girls at greatest risk for eating pathology. 58 girls (age 17.6 yr, range 15–22) with IDDM of > 1 yr duration (8.4 yr) underwent a battery of tests: a) Eating Disorders Inventory(EDI); b) Eating Attitudes Test(EAT-26); & c) HbA1 to assess glycemic control. 27 (46.6%) subjects scored above the cut-off points on the EAT-26 & EDI frequently associated with eating pathology. These individuals then underwent a psychiatric interview: a diagnosis of AN was made in 4.:subjects(6.9%); partial syndrome of AN in 2(3.4%); B in 4, & partial syndrome of B in 2. There was a strong correlation between HbAl & bulimic symptoms, in those with high scores on the bulimia subscale of the EDI(r=0.81,p<0.005); this correlation was even stronger in those with clinical evidence of B(r=0.93,p<0.00l). Clinically significant eating pathology was detected in 20% of this group of adolescent females with IDDM; this represents a 2–fold increase in eating disorders & 6–7–fold increase in AN compared to nondiabetic populations. The presence of eating pathology, particularly B, is associated with poor metabolic control. Thus IDDM may be a major risk factor for the development of eating disorders, which in turn impact negatively upon metabolic control & physical well-being.

Weight suppression, the difference between highest past weight and current weight, is a robust predictor of clinical characteristics of bulimia nervosa; however, the influence of weight suppression in anorexia nervosa (AN) has been little studied, and to our knowledge, no study to date has investigated the ways in which the relevance of weight suppression in AN may depend upon an individual's current body mass index (BMI). The present study investigated weight suppression, BMI, and their interaction as cross-sectional and prospective predictors of psychological symptoms and weight in AN. Women with AN completed depression (Beck Depression Inventory-II) and eating disorder symptomatology measures (Eating Disorder Examination Questionnaire and Eating Disorders Inventory-3) at residential treatment admission (N = 350) and discharge (N = 238). Weight suppression and BMI were weakly correlated (r = -.22). At admission, BMI was positively correlated with all symptom measures except Restraint and Depression scores. Weight suppression was also independently positively correlated with all measures except Weight Concern and Body Dissatisfaction subscale scores. In analyses examining discharge scores (including admission values as covariates), the admission weight suppression × BMI interaction consistently predicted posttreatment psychopathology. Controlling for weight gain in treatment and age, higher admission weight suppression predicted lower discharge scores (less symptom endorsement) among those with lower BMIs; among those with higher BMIs, higher weight suppression predicted higher discharge scores. These results are the first to our knowledge to demonstrate that absolute and relative weight status are joint indicators of AN severity and prognosis. These findings may have major implications for conceptualization and treatment of AN.

This study aimed to compare a sample of females with anorexia nervosa in Singapore with international clinical and population samples from published data in terms of endorsement of risk factors related to anorexia nervosa, severity of eating pathology and levels of psychosocial impairment and to explore the nature of the relationships between the anorexia nervosa risk factors and adherence to Asian cultural values. Data from the Eating Disorder Inventory-3 (EDI-3), the Eating Attitudes Test (EAT-26), the Perceived Sociocultural Pressure Scale (PSPS), the Ideal Body Stereotype Scale (IBSS), the Eating Disorder Examination Questionnaire (EDE-Q), the Clinical Impairment Assessment Questionnaire, and the Asian American Values Scale-Multidimensional (AAVS-M) were collected from 41 female patients (13-31years old) who presented for treatment of anorexia nervosa at the Singapore General Hospital. The profile and presentation of anorexia nervosa in Singapore was comparable to that observed in the Western clinical samples in terms of levels of endorsement of the risk factors for anorexia nervosa. No protective benefit of orientation to Asian culture was found. The observed pattern of general similarity of presentation between Western data and Singaporean data, together with the finding that no protective benefit of orientation to Asian culture was observed, suggests that it may be appropriate to directly apply evidence-based Western models of intervention to the treatment of anorexia nervosa in Singapore.

Symptomatology long-term evolution after hospitalization for anorexia nervosa: Drive for thinness to explain effects of body dissatisfaction on type of outcome

Current Diagnostic and Statistical Manual of Mental Disorders (DSM)-5-based research provides limited data on the use of risperidone on children and adolescents with anorexia nervosa (AN) mainly in small-sample/case report studies. To report the use of risperidone in a group of children and adolescents with feeding and eating disorders, specifically with AN. Observational, naturalistic study. Psychopathology was assessed with Eating Disorders Inventory-3, Beck's Depression Inventory-II, and Symptom Checklist-90-R. Data were reported for the whole sample, for patients treated with risperidone, and finally compared between patients with AN treated with risperidone and those receiving no atypical antipsychotics. Potential differences in admission-discharge changes in body mass index (BMI) and psychopathology were assessed with analyses of covariance corrected for baseline measures. Kaplan-Meier analyses were conducted to assess retention rates of risperidone (at 3 months and 1 year) and rates of rehospitalization on 1-year follow-up. The study enrolled 120 patients with AN (42 treated with risperidone). Risperidone was used for 116.7 (±122.8) days (total exposure = 3979 days) and well-tolerated (nausea, asthenia in one case). No significantly different admission-discharge improvements for BMI or psychopathology were documented for patients treated with risperidone. Risperidone showed a 3-month retention rate of 50.0% (1 year: 9.5%) and was discontinued mainly for the resolution of target symptoms. Cumulative freedom from rehospitalization at 12 months was comparable for treated and untreated patients (hazard ratio = 1.088; Log-rank p = 0.908). This study reports real-life evidence of the use of risperidone in AN children and adolescents in the widest described sample so far. Longitudinal research should assess long-term prognostic factors and tolerability.

The aim of the present study was to determine whether anorexia nervosa (AN), bulimia nervosa (BN) and obsessive-compulsive disorder (OCD) share clinical and psychopathological traits. The sample consisted of 90 female patients (30 OCD; 30 AN; 30 BN), who had been consecutively referred to the Department of Psychiatry, University Hospital of Bellvitge, Barcelona. All subjects met DSM-IV criteria for those pathologies. The assessment consisted of the Maudsley Obsessive-Compulsive Inventory (MOCI), Questionnaire of obsessive traits and personality by Vallejo, Eating Attitudes Test-40 (EAT-40), Eating Disorder Inventory (EDI), and Beck Depression Inventory (BDI). ANCOVA tests (adjusted for age and body mass index) and multiple linear regression models based on obsessive-compulsiveness, obsessive personality traits and perfectionism, as independent variables, were applied to determine the best predictors of eating disorder severity. On ancova several significant differences were found between obsessive-compulsive and eating-disordered patients (MOCI, P < 0.001; EAT, P < 0.001; EDI, P < 0.001), whereas some obsessive personality traits were not eating disorder specific. A total of 16.7% OCD patients presented a comorbid eating disorder, whereas 3.3% eating disorders patients had an OCD diagnosis. In the eating disorder group, the presence of OC symptomatology was positively associated (r = 0.57, P < 0.001) with the severity of the eating disorder. The results were maintained after adjusting for comorbidity. Although some obsessive-compulsive and eating disorder patients share common traits (e.g. some personality traits especially between OCD and AN), both disorders seem to be clinically and psychopathologically different.