Restrictive Anorexia Nervosa Research Articles

Reduced automatic motivational orientation towards food in restricting anorexia nervosa.

A striking and characteristic feature of the restricting subtype of anorexia nervosa (AN) is that they are extremely successful in regulating their food intake in a destructive manner. A possible explanation for the persistent character of their restricted food intake could be a loss of the motivational saliency of food in restricting AN patients. The present study aimed to investigate motivational orientation for food in the restricting subtype of anorexia nervosa with an indirect performance-based measure and a self-report measure of craving. An indirect approach avoidance task was administered to measure automatic approach tendencies for high-fat and low-fat food in restricting adolescent AN-like patients (n=89) and a group of healthy adolescents (n=76). As predicted, restricting AN-like patients showed less automatic motivational orientation toward food than healthy controls. In a similar vein, AN-like patients reported less craving for food than the group of healthy controls. The loss of an automatic motivational orientation toward food together with the deliberate strategy to avoid food might help explain the ability of restricting AN-like patients to regulate their food intake.

Perception of emotion and bilateral advantage in women with eating disorders, their healthy sisters, and nonrelated healthy controls

Eating disorders (EDs) are characterized not only by disordered eating, but also by other psychopathology. In this exploratory study, we examined the ability of women with different diagnoses of EDs, their unaffected sisters, and healthy unrelated controls to recognize their own and other's emotions. We also looked at interhemispheric integration of emotion recognition and its relationship with depression. Five groups of women participated: 1. anorexia nervosa restricting (AN-R) and 2. (AN-B/B) binge/purge, 3. bulimia nervosa binge/purge, (BN-B/P), 4. healthy sisters of women with ED, and 5. unrelated healthy controls. We used two questionnaires measuring alexithymia and depression, and two lateralized experimental tasks requiring recognition of facial emotion. Unilateral versus bilateral presentation allow the indexing of interhemispheric integration. Alexithymia: All the ED groups were found to be more alexithymic and depressed on the self report scales compared to the two healthy groups. Depression completely mediated alexithymia in the AN-R group but not in the AN-B/P and BN-B/P patients. Sisters of ED women were more alexithymic than unrelated controls. Lateralized facial emotion recognition: ED women showed no deficits in recognizing basic emotions. However, the clinical groups did not show a bilateral advantage whereas the two healthy groups did so. We present three conclusions: we show, for the first time, evidence for a deficit in hemispheric integration in EDs. This implies that EDs may be a disconnection syndrome; alexithymia characterizes women with EDs and members of their family; depression is manifested differently in AN-R, than in women who binge/purge.

Endocrine Alterations Are the Main Determinants of Cardiac Remodelling in Restrictive Anorexia Nervosa

Objective. Anorexia nervosa is a condition of reduced hemodynamic load, characterized by varying degrees of cardiac remodelling, only in part related to reduced body mass; the mechanism for such variability, as well as its clinical significance, remains unknown. Aim of the study was to assess the possible influence of a great number of clinical, biochemical, and endocrine factors on cardiovascular parameters in restrictive anorexia nervosa. Method. Twenty-five female patients hospitalized for restrictive anorexia nervosa underwent extensive cardiovascular, clinical, and biochemical evaluation. Results. Height-adjusted and cardiac workload-matched left ventricular mass was significantly related to several endocrine parameters, blood pressure, and vasoreactivity. On multivariate analysis, IGF/GH ratio and systolic blood pressure were the only independent predictors of height-adjusted ventricular mass (adj-R 2 = 0.585; P = 0.001); when matching for cardiac workload, left ventricular mass was independently predicted only by GH and FT3 levels. All effects were independent of patient's weight and BMI. Conclusions. Indices of endocrine impairment seem to be the most relevant determinants of left ventricular hypotrophy in anorectic patients, apparently independent of reduced hemodynamic load and BMI. In particular, IGF/GH ratio and FT3 seem to particularly affect left ventricular mass in this population.

Posttraumatic Stress Disorder in Anorexia Nervosa

Comorbidity among eating disorders, traumatic events, and posttraumatic stress disorder (PTSD) has been reported in several studies. The main objectives of this study were to describe the nature of traumatic events experienced and to explore the relationship between PTSD and anorexia nervosa (AN) in a sample of women. Eight hundred twenty-four participants from the National Institutes of Health-funded Genetics of Anorexia Nervosa Collaborative Study were assessed for eating disorders, PTSD, and personality characteristics. From a final sample of 753 women with AN, 13.7% (n = 103) met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for PTSD. The sample mean age was 29.5 (standard deviation = 11.1) years. In pairwise comparisons across AN subtypes, the odds of having a PTSD diagnosis were significantly lower in individuals with restricting AN than individuals with purging AN without binge eating (odds ratio = 0.49, 95% confidence interval = 0.30-0.80). Most participants with PTSD reported the first traumatic event before the onset of AN (64.1%, n = 66). The most common traumatic events reported by those with a PTSD diagnosis were sexually related traumas during childhood (40.8%) and during adulthood (35.0%). AN and PTSD do co-occur, and traumatic events tend to occur before the onset of AN. Clinically, these results underscore the importance of assessing trauma history and PTSD in individuals with AN and raise the question of whether specific modifications or augmentations to standard treatment for AN should be considered in a subgroup to address PTSD-related psychopathology.

Approach and avoidance motivation in eating disorders

It has been proposed that approach and avoidance processes may be critically involved in the development and maintenance of eating disorders (EDs), including anorexia nervosa (AN) and bulimia nervosa (BN). The Behavioural Inhibition System and Behavioural Activation System Scales (BIS/BAS) and Appetitive Motivation Scale (AMS) questionnaires were administered to 286 participants: 91 healthy controls (HCs), 121 participants with a current ED, either AN (restrictive and binge purge subtypes), or BN and 74 participants recovered from an ED. Individuals with EDs had higher levels of sensitivity to punishment and lower levels of reward reactivity than controls. Individuals in recovery from an ED scored the same as those in the acute group, with the exception of BAS fun seeking, for which they scored significantly higher than those with restricting AN. Discriminant analysis revealed that HCs were maximally separated from those in the acute and recovered ED groups along a dimension reflecting high punishment sensitivity and low reward sensitivity. Classification analysis demonstrated that ED and HC group membership was predicted from reward and punishment sensitivity measures; however recovered participants tended to be misclassified as ED. This study suggests high punishment sensitivity and low reward reactivity/sensitivity might form a personality cluster associated with the risk of developing an ED.

Restrictive Anorexia Nervosa and Set-Shifting in Adolescents: A Biobehavioral Interface

Set-shifting is a neurocognitive concept defined as the ability to switch tasks flexibly. Set-shifting scores are worse in adults with restrictive anorexia nervosa (AN-R) than in controls. Adolescence is a developmental period when young people must respond flexibly to new situations. The purpose of this study was to compare the set-shifting scores of 24 adolescent females with AN-R with 37 matched normal adolescent controls (ages, 14-20). Methods used for the study included sociodemographic, psychological, and biological data, and neurocognitive testing using the Behavior Rating of Executive Function - Self- and Parent-Reports, the Cambridge Neuropsychological Automated Battery, and the Wisconsin Card-Sorting Test. Statistical analyses included t-tests, multiple analysis of variance, and correlations. Sociodemographic data and intelligence quotient of study and control subjects were similar. There were differences in body mass index and the Eating Disorder Inventory-3 evaluation. Significant differences in the composite score of set-shifting between the study and control groups were found using multiple analysis of variance. Adolescent females with AN-R had significantly worse set-shifting scores than the control subjects. Future studies of adolescent AN-R subjects should include biological (functional magnetic resonance imaging) and neurocognitive measures to determine the mechanisms at the brain-behavioral interface so that treatment can be directed specifically to set-shifting deficits.

Bulimia nervosa with history of anorexia nervosa: Could the clinical subtype of anorexia have implications for clinical status and treatment response?

To investigate whether the subtype of anorexia nervosa (AN) could influence the bulimic syndrome and treatment response in bulimia nervosa (BN) patients with a history of AN (BN/AN+). Seventy female BN patients were assessed for eating disorder, psychopathology and personality, and treated for 6 months. BN/AN+ patients retained some traits of their past condition: lower body weight, higher perfectionism, and higher reward dependence. They also had more severe symptoms, longer evolution time, and worse response to treatment. A history of restricting AN was associated to higher age, longer evolution time, higher impulsivity, and greater tendency to use diet pills and diuretics. A history of binge-purging AN was associated to more severe vomiting, lower body dissatisfaction and less depressive symptoms, as well as better outcome. The influence of the AN subtype in BN/AN+ patients is worthy of further study as it might have clinical implications.

Ghrelin reactive autoantibodies in restrictive anorexia nervosa

Objective Subjects with restrictive anorexia nervosa (AN) display increased basal plasma levels of ghrelin that normalize after refeeding. The mechanism responsible for increased ghrelin levels in AN is unknown. We studied if changes of ghrelin reactive autoantibodies (autoAbs) could explain elevated plasma ghrelin in AN. Methods Plasma levels of autoAbs reactive with ghrelin and des-acyl ghrelin were measured by enzyme-linked immunosorbent assay in subjects with AN before and 1 mo after hospitalization (refeeding) and compared with healthy controls and with plasma levels of ghrelin peptides. Results Decreased levels of immunoglobulin (Ig) G, IgM, and IgA classes of autoAbs reacting with acyl ghrelin were found in patients with AN. Addition of des-acyl ghrelin but not of acyl ghrelin peptides at 10 −8 M to plasma before enzyme-linked immunosorbent assay showed in patients with AN but not in controls high levels of IgG autoAbs reacting with des-acyl ghrelin as a result of dissociation of des-acyl ghrelin autoAbs in immune complexes. Plasma levels of acyl and des-acyl ghrelin peptides correlated negatively with des-acyl ghrelin IgG autoAbs. Body mass index, which improved after refeeding, correlated with an increase of acyl ghrelin IgM autoAbs. Conclusion These results show that in patients with AN, ghrelin IgG autoAbs exist mainly as immune complexes with des-acyl ghrelin accompanied by a decrease of a free fraction of these autoAbs binding acylated and des-acyl ghrelin. This decrease of bioavailable ghrelin autoAbs may underlie a long-term elevation of plasma ghrelin levels and the resulting phenomenon of ghrelin resistance in malnourished patients with AN.

Amygdala hyperreactivity in restrictive anorexia nervosa

Functional imaging studies had often investigated heterogeneous samples of anorexia nervosa (AN) patients with varying paradigms and methodologies that had resulted in divergent results. The present study aimed to examine these issues by studying a well-defined sample of restrictive AN patients with a disorder-specific paradigm which had been used previously. Subjects showed increased blood oxygen level dependent responses of the cingulate, frontal, insular and parietal cortices. Group comparisons demonstrated increased activity of the right amygdala in the sample of restrictive AN patients. Our results are in support of other recently published functional imaging studies and point to a pivotal role of the right amygdala in AN. Signals of the midcingulum were reduced in comparison to healthy controls. The constellation of increased activity of the amygdala and decreased activity of the cingulate cortex likely represents parts of a negative feedback loop of emotional processing. Disgust ratings correlated with the amygdala signal negatively, which points to the complex role of this structure within eating disorders.

Purging disorder: Psychopathology and treatment outcomes

To characterize a tertiary care treatment-seeking sample and assess post-treatment remission and completion rates for purging disorder (PD). Consecutively admitted women with PD (n = 122), anorexia nervosa (AN) restricting subtype (AN-R; n = 146), AN binge-purge subtype (AN-B; n = 154), and bulimia nervosa-purging subtype (BN-P; n = 415) were compared on general and eating disorder specific psychopathology. A subsample (n = 256) attended a day treatment program and were assessed for post-treatment remission and completion rates. PD occurred in 17.3% of eating disorders not otherwise specified and 6.7% of total eating disorder referrals. PD patients were similar to AN-B and BN-P, but had higher levels than AN-R, on general and eating disorder psychopathology. PD individuals did not have different post-treatment remission or completion rates compared to other eating disorders. The results add to a growing literature on the utility of PD as a diagnosis.

Reduced capacity in automatic processing of facial expression in restrictive anorexia nervosa and obesity

There is growing evidence that disordered eating is associated with facial expression recognition and emotion processing problems. In this study, we investigated the question of whether anorexia and obesity occur on a continuum of attention bias towards negative facial expressions in comparison with healthy individuals of normal weight. Thirty-three patients with restrictive anorexia nervosa (AN-R), 30 patients with obesity (OB) and 63 healthy age and social–economic status matched controls were recruited. Our results indicated that AN-R patients were more attentive to angry faces and had difficulties in being attentive to positive expressions, whilst OB patients had problems in looking for or being attentive to negative expressions independently of self-reported depression and anxiety. Our findings did not support the idea that AN-R and OB occur on a continuum. We found that AN-R was associated with a reduced capacity in positive facial expression processing, whereas OB was associated with a reduced capacity in negative facial expressions processing. The social relevance of our findings and a possible explanation based upon neuroscience are discussed.

Depression and eating disorders: Treatment and course

BackgroundWe examined the course of major depressive disorder (MDD) and predictors of MDD recovery and relapse in a longitudinal sample of women with eating disorders (ED). Methods246 Boston-area women with DSM-IV anorexia nervosa-restricting (ANR; n=51), AN-binge/purge (ANBP; n=85), and bulimia nervosa (BN; n=110) were recruited between 1987 and 1991 and interviewed using the Eating Disorders Longitudinal Interval Follow-up Evaluation (LIFE-EAT-II) every 6–12months for up to 12years. 100 participants had MDD at study intake and 45 developed MDD during the study. Psychological functioning and treatment were assessed. ResultsTimes to MDD onset (1week–4.3years), recovery (8weeks–8.7years), and relapse (1week–5.2years) varied. 70% recovered from MDD, but 65% subsequently relapsed. ANR patients were significantly less likely to recover from MDD than ANBP patients (p=0.029). Better psychological functioning and history of MDD were associated with higher chance of MDD recovery. Higher baseline depressive severity and full recovery from ED were associated with greater likelihood of MDD relapse; increased weight loss was somewhat protective. Adequate antidepressant treatment was given to 72% of patients with MDD and generally continued after MDD recovery. Time on antidepressants did not predict MDD recovery (p=0.27) or relapse (p=0.26). LimitationsSmall ED diagnostic subgroups; lack of non-ED control group. ConclusionsThe course of MDD in EDs is protracted; MDD recovery may depend on ED type. Antidepressants did not impact likelihood of MDD recovery, nor protect against relapse, which may impact on treatment strategies for comorbid MDD and EDs.

Suicide attempts in anorexia nervosa subtypes

Objective The risk for suicide attempts is elevated in anorexia nervosa (AN), yet we know little about the relation between suicide and personality in this group. We explored the prevalence of lifetime suicide attempts in women with AN and compared those who had and had not attempted suicide on eating disorder symptoms, general psychopathology, and personality both relative to a healthy control group and then across AN subtypes. Method One hundred four outpatients with restricting AN, 68 outpatients with purging AN, and 146 comparison individuals participated in the study. Results The prevalence of suicide attempts differed significantly across the 3 groups ( P = .003), with 0% in the controls, 8.65% in the restricting AN group, and 25.0% in the purging AN group. Depression measures were elevated in those with suicide attempts. Within the restricting AN group, those who attempted suicide scored significantly higher on Phobic Anxiety, measured by means of the Symptom Checklist–Revised, than those who did not ( P = .001). Conclusion The presence of purging and depressive symptoms in individuals with AN should increase vigilance for suicidality; and among restrictors, greater anxiety may index greater suicide risk.

Outcomes of Empirical Eating Disorder Phenotypes in a Clinical Female Sample: Results from a Latent Class Analysis

Background/Aims: To empirically classify phenotypes of eating disorders (ED) using latent class analysis (LCA), and to validate this classification based on clinical outcomes. Methods: LCA was applied to 968 inpatients. The resultant classes were validated by clinical outcomes including mortality. Results: A 5-class solution showed the best fit. The symptoms of latent class 1 (LC1; 26% of the sample) resembled anorexia nervosa (AN), bingeing-purging (AN-B/P) subtype; those of LC2 (23%) resembled bulimia nervosa; those of LC3 (11%) were close to AN-B/P without weight and body concerns; those of LC4 resembled restrictive anorexia nervosa (RAN) without weight and body concerns, and those of LC5 RAN. A history of hospitalization for ED was significantly more frequent for LC3 and LC4. The lowest BMI at admission were presented in LC4. LC1 showed the highest level of psychological disturbances and LC4 the lowest. LC3 and LC4 differed from LC1 and LC5 by higher percentages of treatment dropout (64.9 vs. 57.2 and 55.7 vs. 47.5%, respectively; overall p = 0.001). Survival rates tended to be different between the LC (p = 0.09). Conclusions: Subgroups of AN patients with low weight and body concerns seem more severe at hospitalization and more difficult to manage, with a higher rate of treatment dropout than the ‘typical’ AN patients.

Functional neuroimaging in anorexia nervosa: A clinical approach

Aims To provide a review of the available literature about the functional neuroimaging of anorexia nervosa, and to summarize the possible role of neurobiological factors in its pathogenesis. Methods A systematic review of the literature was performed using PubMed and Medline electronic database (1950–September 2009). Eligible studies were restricted to those involving the main parameters of cerebral activity and functional neuroimaging techniques. Findings of the reviewed studies have been grouped on a diagnostic subtype basis, and their comparison has been interpreted in terms of concordance. Results We found a high level of concordance among available studies with regard to the presence of frontal, parietal and cingulate functional disturbances in both anorexia nervosa restricting and binge/purging subtypes. Concordance among studies conducted regardless of the anorexia nervosa subtypes suggests an alteration in temporal and parietal functions and striatal metabolism. Conclusions The most consistent alterations in anorexia nervosa cerebral activity seem to involve the dorsolateral prefrontal cortex, the inferior parietal lobule, the anterior cingulate cortex and the caudate nucleus. They may affect different neural systems such as the frontal visual system, the attention network, the arousal and emotional processing systems, the reward processing network, and the network for the body schema.

Attachment Insecurity Predicts Eating Disorder Symptoms and Treatment Outcomes in a Clinical Sample of Women

We examined the extent to which attachment insecurity was related to eating disorder (ED) symptoms, and predictive of treatment outcomes. Women diagnosed with anorexia nervosa (AN) restricting subtype (ANR), AN binge purge subtype (ANB), or bulimia nervosa (BN) completed an attachment scale pretreatment, and ED symptom scales pretreatment (N = 243) and post-treatment (N = 157). A comparison sample of 126 non-ED women completed attachment scales on 1 occasion. Those with EDs had significantly higher attachment insecurity than non-ED. ANB was associated with higher attachment avoidance compared with ANR and BN, and higher attachment anxiety compared with BN. Higher attachment anxiety was significantly related to greater ED symptom severity and poorer treatment outcome across all EDs even after controlling for ED diagnosis. Attachment dimensions substantially contribute to our understanding of ED symptoms and treatment outcome. Addressing attachment insecurity when treating those with EDs may improve treatment outcomes.

A ghrelin gene variant may predict crossover rate from restricting-type anorexia nervosa to other phenotypes of eating disorders: a retrospective survival analysis

Patients with anorexia nervosa restricting type (AN-R) often develop bulimic symptoms and crossover to AN-binge eating/purging type (AN-BP), or to bulimia nervosa (BN). We have reported earlier that genetic variants of an orexigenic peptide ghrelin are associated with BN. Here, the relationship between a ghrelin gene variant and the rate of change from AN-R to other phenotypes of eating disorders (EDs) was investigated. Participants were 165 patients with ED, initially diagnosed as AN-R. The dates of their AN-R onset and changes in diagnosis to other subtypes of ED were investigated retrospectively. Ghrelin gene 3056 T-->C SNP (single nucleotide polymorphism) was genotyped. Probability and hazard ratios were analyzed using life table analysis and Cox's proportional hazard regression model, in which the starting point was the time of AN-R onset and the outcome events were the time of (i) onset of binge eating, that is, when patients changed to binge eating AN and BN and (ii) recovery of normal weight, that is, when patients changed to BN or remission. Patients with the TT genotype at 3056 T-->C had a higher probability and hazard ratio for recovery of normal weight. The ghrelin SNP was not related with the onset of binge eating. The 3056 T-->C SNP of the ghrelin gene is related to the probability and the rate of recovery of normal body weight from restricting-type AN.

Investigation of factors associated to crossover from anorexia nervosa restricting type (ANR) and anorexia nervosa binge-purging type (ANBP) to bulimia nervosa and comparison of bulimia nervosa patients with or without previous ANR or ANBP

Objective To characterize factors associated to diagnostic crossover from anorexia nervosa restricting type (ANR) and anorexia nervosa binge-purging type (ANBP) to bulimia nervosa (BN) and to compare BN individuals with initial ANR or ANBP to subjects with stable BN. Method Two hundred thirty-eight patients with current and lifetime diagnosis of AN or BN underwent diagnostic, psychopathological, and historical examinations by means of ad hoc clinical interviews and rating scales. Results One hundred twenty-three individuals had a stable BN. Seventy patients had a diagnosis of ANR and 45 of ANBP at the time of disease onset; 24 ANR patients and 23 ANBP subjects developed BN, whereas 46 ANR patients and 22 ANBP subjects did not crossover. Although the rate of diagnostic crossover was higher in the ANBP group than in the ANR one, the difference was not statistically significant. Longer illness duration, higher maximum past body mass index (BMI), higher novelty seeking, and lower self-directedness resulted significantly associated to crossover from ANR to BN, whereas higher maximum past BMI, higher desired body weight, higher novelty seeking, and lower harm avoidance were significantly associated to crossover from ANBP to BN. As compared to stable BN subjects, BN patients with initial ANR exhibited lower minimum past BMI, lower desired body weight, higher drive for thinness, ascetism, and social insecurity scores; BN patients with initial ANBP exhibited lower minimum past BMI and decreased enteroceptive awareness scores. Conclusions Different clinical and personality factors seem to be associated to crossover from ANR and ANBP to BN. Moreover, BN with initial ANR seems to differ clinically from stable BN. These findings may have therapeutic and prognostic implications.

Predictors of Neuropsychological Recovery in Treatment for Anorexia Nervosa

Previous research indicates that individuals with Anorexia Nervosa (AN) often experience some degree of neuropsychological dysfunction. Although most aspects of cognition improve with treatment, factors that predict neuropsychological improvement remain elusive. The present study investigated whether cognitive reserve, the estimated level of premorbid cognitive functioning, and AN subtype predicted neuropsychological improvement during inpatient treatment for AN. Neuropsychological functioning was assessed pre- and post-hospitalization in 28 women with AN (18 with restricting type and 10 with binge-eating/purging type), and cognitive reserve was estimated at admission using a word reading test. Level of cognitive reserve and AN subtype were both significant predictors of neuropsychological improvement in this sample. Cognitive reserve was significantly associated with improvements in verbal memory, semantic fluency, basic auditory attention and visuospatial construction. Participants with AN binge-eating/purging type demonstrated significantly greater neuropsychological improvement during treatment than did participants with AN restricting type. Information about cognitive reserve and AN subtype may provide clinicians with valuable prognostic information and help guide treatment.

Pleasure for visual and olfactory stimuli evoking energy-dense foods is decreased in anorexia nervosa

Although patients with anorexia nervosa have been suggested to be anhedonic, few experiments have directly measured their sensory pleasure for a range of food and non-food stimuli. This study aimed to examine whether restrictive anorexia nervosa (AN-R) patients displayed: i) a generalized decline in sensory pleasure or only in food-related sensory pleasure; ii) a modification of hedonic responses to food cues (liking) and of the desire to eat foods (wanting) as a function of their motivational state (hunger vs. satiety) and energy density of foods (high vs. low). Forty-six female participants (AN-R n = 17; healthy controls (HC) n = 29) reported before/after lunch their pleasure for pictures/odorants representing foods of different energy density and non-food objects. They also reported their desire to eat the foods evoked by the sensory stimuli, and completed the Physical Anhedonia Scale and the Beck Depression Inventory. AN-R and HC participants did not differ on liking ratings when exposed to low energy-density food or to non-food stimuli. The two groups also had similar physical anhedonia scores. However, compared to HC, AN-R reported lower liking ratings for high energy food pictures regardless of their motivational state. Olfactory pleasure was reduced only during the pre-prandial state in the AN-R group. The wanting ratings showed a distinct pattern since AN-R participants reported less desire to eat the foods representing both low and high energy densities, but the effect was restricted to the pre-prandial state. Taken together these results reflect more the influence of core symptoms in anorexia nervosa (fear of gaining weight) than an overall inability to experience pleasure.