Detection of anorexia nervosa in primary care

In the years preceding diagnosis, individuals with anorexia nervosa (AN) attend more primary care appointments than their peers. Primary care physicians (PCPs) may be uniquely situated to detect AN in early manifestations. In this study, a sample of physicians was recruited online. Videotaped vignettes of a primary care appointment were shown to these participants, who were asked to diagnose the patient and could make a referral. 61.2% of participants identified an eating disorder (ED) diagnosis. However, of those, only 40% intended to refer for therapy. These findings suggest that the rate of referral to mental health is problematically low among PCPs     

Reconceptualizing anorexia nervosa

Anorexia nervosa (AN) has one of the highest mortality rates of any psychiatric disorder. Treatments are often ineffective and relapse is common. Most research attempting to understand the underlying causes and maintenance factors of AN has focused on environmental contributions, yet there is much to be explored in terms of biological risk and maintenance factors. In this paper, we focus primarily on AN research related to genetics and the complex microbial community in the gut (intestinal microbiota), and how these impact our conceptualization of this disorder. Emerging research identifying significant negative genetic correlations between AN and obesity suggests that the conditions may represent ‘metabolic bookends’. The identification of underlying biological mechanisms may provide both insight into extreme weight dysregulation on both ends of the spectrum and new possible points of entry for AN treatment. Additionally, the reported microbial imbalance (dysbiosis) in the gut microbiota in AN patients, potentially due to a nutrient‐ and energy‐deprived gut environment, implies alterations in functional and metabolic capacity of the gut microbiome. The extent to which AN and obesity can also be considered to be ‘microbiome bookends’ requires further investigation. Finally, we discuss ongoing and future AN projects exploring the interplay between host genomics, the environment, and cumulative microbial genomes (microbiome) as well as interventions at the microbial and gut level.     

Psychoneuroendocrinology of anorexia nervosa

It is suggested that the symptoms of anorexia nervosa are physiological responses to starvation. There is no evidence of a neural or non-neural dysfunction that predisposes women for anorexia nervosa and the endocrine and psychological consequences of starvation are reversed once patients have re-learnt how to eat and regained a normal body weight. Because variability in the supply of food may be a common evolutionary condition, it is more likely that body weight is variable than constant in normal circumstances. The role of the neuroendocrine system in times of feast and famine is to allow the individual to adopt behavioral strategies as needed rather than maintaining body weight homeostasis. Treatment of anorexic patients should aim at reducing their high level of physical activity in order to facilitate eating.     

Self-forgiveness in anorexia nervosa and bulimia nervosa

This study investigated whether low levels of self-forgiveness were associated with eating disorder symptomatology. Participating women (N = 51) had diagnoses of anorexia nervosa, bulimia nervosa, or no eating disorder diagnosis. They completed 3 measures of self-forgiveness. Women with eating disorders had lower levels of self-forgiveness compared with control participants. Results suggest that incorporating self-forgiveness interventions into current eating disorder treatments should be evaluated in future research as they might enhance clinical outcomes.     

Stealing in anorexia nervosa and bulimia nervosa

Only recently stealing behaviour has been noticed as a symptom of anorexia nervosa and bulimia nervosa. Reviewing our sample of 63 patients we discuss the incidence and motivation of kleptomania. In 24% of our patients stealing behaviour was reported which is a definitely high rate compared to literature. Among the intentions for stealing behaviour we found: Stealing as conversion of revenge, self-assertiveness compensation of binge-eating or stealing as achievement. The differential motivation of stealing should be considered in legal consequences.     

Phenylketonuria and anorexia nervosa

ABSTRACT. A girl with phenylketonuria and mild mental retardation developed a behaviour disorder and anorexia nervosa at the age of 14. The anorexic symptoms disappeared at the age of 20, but the behaviour disorder worsened, leading to compulsory detention in a psychiatric hospital. Serum phenylalanine levels may have influenced the course of the disorder.     

Blindness and anorexia nervosa

Two cases of anorexia nervosa in blind patients are reported. They demonstrate that blind children experience many developmental problems which are thought to be important in the etiology of anorexia nervosa. Similarly, blind children are unusually susceptible to misperceive their body size and weight. The apparent absence of a strong association between congenital blindness and anorexia nervosa challenges the presumed aetiological link between disturbed body image and identity diffusion, and anorexia nervosa.     

Osteoporosis in anorexia nervosa

Osteoporosis is common in anorexia nervosa. It places these patients at increased lifetime risk for fractures. Bone loss may never recover completely even once weight is restored. The strongest predictors of osteoporosis include low body weight and amenorrhea. Loss of bone density can occur rapidly and very early in the course of anorexia nervosa. The etiology of bone loss in the patient with anorexia nervosa is multifactorial. In addition to reduced estrogen and progesterone, excess cortisol levels and low levels of insulin growth factor (IGF-1), a correlate for bone formation, are observed. Dual energy x-ray absorptiometry screening is important to assess bone density. However, successful treatments to reverse bone loss, in those with anorexia nervosa, are lacking. Early diagnosis and treatment of anorexia nervosa are paramount to prevent initial weight loss and subsequent loss of bone.     

Pharmacotherapy for anorexia nervosa and bulimia nervosa

Psychotherapy is the treatment of choice for both anorexia nervosa and for bulimia nervosa. However, many patients are also treated by pharmaceutical drugs. For the clinician it is difficult to choose pharmacotherapy, because the drugs may not be licensed, because of pharmacodynamic problems due to underweight or purging behaviour, or because of comorbidity. The present review summarises the current knowledge on pharmacotherapy for anorexia nervosa and bulimia nervosa considering the available guidelines. In general, the knowledge based on studies is insufficient for anorexia nervosa. Up to now, there is no proof of efficacy for any antidepressant or atypical antipsychotic with respect to weight gain; atypical antipsychotics may be helpful for ruminating or excessive motor hyperactivity. For bulimia nervosa antidepressants are the pharmacotherapy of first choice. Long-term effects, however, are still unknown.     

The endocrinology of anorexia nervosa and bulimia nervosa

Considerable evidence exists of hypothalamic dysfunction in patients with anorexia nervosa and bulimia nervosa. This dysfunction is reflected in disturbances of endocrine function including abnormalities of gonadotropin, growth hormone, and corticotropin-releasing hormone secretion. Whereas these disturbances are generally reversed with nutritional rehabilitation and weight restoration, it is not evident to what extent nutritional factors are the primary etiology or whether they unmask an otherwise existing but compensated central disturbance. Similarly, endocrine disturbances may be a final common pathway in which disturbances of diet, weight, activity, stress, and mood as well as hypothalamic dysfunction are expressed.