Thursday, October 12, 2017

Q&A: Endocrine Problems Among Men with AN

Vol. 28 / No. 5  

Q: I’ve read a lot about the endocrine problems among women with AN, but not much about hormonal dysfunction among men with AN. How common are these effects in male patients? (G.V., Los Altos, CA)
A: An article by Dr. Aren Skolnick from Long Island Jewish Medical Center, New Hyde Park, NY, and fellow endocrinologists at the Carl Icahn School of Medicine, St Luke’s Hospital, NY, NY, adds some helpful perspectives on this very subject. The authors reported four cases of young men with hormonal dysfunction (AACE Clin Case Rep. 2016;2:e351) due to underlying AN; these cases lay out the variety of problems that can be seen in men severely ill with AN.
The first was a 24-year-old man with AN hospitalized for bradycardia and a hospital course who developed abnormal liver tests, pancreatitis, pneumomediastinum, and refeeding syndrome. Over the past year his weight had dropped from 220 lb to 79 lb as he took the product Hydroxycut®, drastically cut back his food intake, and took up a rigorous exercise program, including running 10 miles each day. On examination, he was found to have bradycardia and low blood pressure. His BMI was 12. Endocrine studies showed a TSH level of 1.28 µIU/mL (normal range: 0.34 to 5.60), free T4 level of 0.7 ng/dL (normal: 0.6 to 1.1), and free T3 of 1.1 pg/mL (normal: 2.5 to 3.9), and a total T3 reading of 31 ng/dL (normal: 8 to 178). Two-dimensional echocardiography showed an ejection fraction of only 19%, indicating significant heart dysfunction. He had a complicated hospital course that lasted 7 months and he was referred to a rehabilitation facility.
The second patient was a 20-year-old with a BMI of 12.9. He first sought help for erectile dysfunction and was started on testosterone replacement therapy. Worsening fatigue and constipation were more recent complaints. When he was seen again, he seemed severely cachectic with sarcopenia. He was arousable but could not speak. Like the first patient, he had bradycardia. His lab workup showed a capillary blood glucose level of 50 mg/dL, and abnormal liver function tests. The repeat finger-stick glucose level was 15 mg/dL, and his TSH level was 2.6 µIU/mL (normal: 0.34 to 5.60). His T4 level was 0.8 ng/dL (normal:0.6 to 1.1), and the total T3 level was 20 ng/dL (normal: 87 to 178).
The third patient, a 23-year-old, presented after losing 35 lb over the prior 2 months. His pulse and blood pressure were low, and his BMI was 13. He was hypoglycemic (50 mg/dL) and had bradycardia and hypothermia. Endocrine lab studies showed a TSH of 0.82 IU/mL (normal: 0.34 to 5.60), a low testosterone level of 198 ng/dL (normal: 249 to 836), and extremely low follicle- stimulating hormone levels and thyroid levels.
The last patient was a 20-year-old male who had lost 130 lb over the prior 6 months. His BMI was 18. His lab tests showed severe hypokalemia, 2 mmol/L (normal: 3.1 to 5.1) hypochloremia, and elevated bicarbonate. He developed bradycardia (pulse 39 to 49 beats/minute) hypothermia, and hypotension. His endocrine workup showed TSH at 2.0 µIU/mL, freeT4 at 1.72 µIU/mL (normal: 0.8-1.8), hemoglobin A1c 5.5%, among other findings.
All four of these young men had protein-calorie malnutrition, hypothermia, hypotension, and bradycardia and then were found to have multiple endocrinopathies. Three of the young men had no previous diagnoses of AN or another ED and thus AN was not considered early on. Three of the four also has some signs of elevated cortisol levels, hypothyroidism and hypogonadism.
These four cases point out that various endocrine disturbances can occur in men with AN. That three of the four had not been previously diagnosed with AN despite having fairly severe symptoms underscores the challenges with case finding in AN. -SC

Does Teasing Lead to Disordered Eating?

Vol. 28 / No. 5  

Results differed in two studies; one added changes over time.
Teasing about weight and bullying in adolescence is believed to influence the development of abnormal eating behaviors and attitudes. However, Spanish researchers recently reported finding no significant or independent effects from teasing on eating behaviors (Rev Psquiatr Salud Ment. 2017; Aug 14. doi:10.1016/j.rpsm.2017; Epub ahead of print).
The two-year prospective study of 7167 adolescent females and males between 13 and 15 years of age used the Perception of Teasing Scale, or POTS, questionnaire to measure the effects of teasing about weight and general abilities. The association of teasing to eating psychopathology 2 years later was analyzed, controlling for body mass index (BMI), and measures of body dissatisfaction, drive to thinness, perfectionism (Eating Disorders Inventory), emotional symptoms, and hyperactivity, measured at the first assessment.
Teasing about weight or teasing about abilities did not impact onset of later eating psychopathology. The results were similar for boys and girls, with one exception. In girls, but not in boys, controlling BMI was enough to make any earlier effect of teasing disappear, according to the authors.
A different result in a second, larger study
The results from the Spanish study contrasted with those from a longitudinal cohort study (Project EAT) that followed a diverse sample of 1830 adolescents from 1999 to follow-up in 2015 (Prev Med.2017; Jul;100:173. doi: 10.1016/j.ypmed.2017.04.023. Epub 2017 Apr 24). The relationship of weight-based teasing at baseline was examined as a predictor of weight status, binge eating, dieting, eating as a coping strategy, unhealthy weight control methods, and body image 15 years later. Dr. Rebecca M. Puhl of the University of Connecticut, Hartford, and colleagues wanted to identify whether weight-based teasing during adolescence would predict adverse eating and weight-related outcomes, and to differentiate which source of teasing (by peers or family members) had an impact on the outcome.
Teasing about weight did have later repercussions
Teasing about weight during adolescence predicted higher BMI and obesity 15 years later. For women, these long-term associations occurred across peer and family-based teasing; in contrast, only teasing by peer members predicted higher BMIs among men at long-term follow-up.
Weight-based teasing from peers and family during the teen years also predicted subsequent binge eating, unhealthy weight control methods, eating to cope, poor body image, and recent dieting in women 15 years later.
In some ways these findings contradict, but taken into consideration with other work in this area, the impact of teasing remains a major concern.

Purging Behaviors and Sleep Disturbances

Vol. 28 / No. 5  

In a study from Japan, disturbed sleep was dramatically different in those with purge-type AN.
Disturbed sleep is a common complaint among patients with mood or anxiety disorders and is also common among those with EDs. For example, in one earlier study of 549 college women, 30% of those with an eating disorder (AN, BN, or BED) complained of insomnia, compared to 5% of participants without an eating disorder (Eat Behav. 2014; 15:686).
In the first study to focus on the effects of purging behaviors among patients with EDs and how this affects sleep quality, Dr. Tokusei Tanahashi and his team studied a group of female inpatients with a primary diagnosis of AN (BioPsychoSocial Med. 2017; 11:22). The team wanted to understand how purging behaviors relate to sleep quality and patterns, and which disordered eating behaviors, such as binge-eating, vomiting, or laxative abuse, might affect global sleep quality among female patients with AN. Their study group included 20 consecutive female inpatients with a primary diagnosis of AN who were admitted to the Department of Psychosomatic Medicine at Kohnodai Hospital, Chiba, Japan, during a 6-month span.
The study participants completed the Japanese version of the Pittsburgh Sleep Quality Index, which assesses the quality and disruption of sleep. Then, using the raw data provided by the questionnaire, the authors recorded each individual’s sleep-onset time, wake-up time, and sleep duration. The team also administered the Center for Epidemiologic Studies Depression scale (CES-D) to assess depression. Of the initial group of 86 patients with eating disorders, 23 diagnosed with AN were found to be eligible for further study. Three women with binge eating-purging type AN (AN-BP) did not consent to entering the study, so the final group included 20 women from 15 to 58 years of age (8 with AN-R, 12 with AN-BP), and the mean duration of illness was 7.2 years in those with AN-BP, 2.6 years among those with AN-R. BMI was 13.7 mg/k2 in the AN-BP group and 12.6 in the AN-R group
One group had poorer quality of sleep
The authors found that patients with AN-BP had dramatically worse global sleep quality and more disrupted circadian rhythm and abnormal sleep duration than did patients with AN-R. Impaired sleep patterns ( a score of 5 or more on the PSQI) were reported in 2 of 8 participants with AN-R (25%), compared with 9 or 12 patients with AN-BP (75%). Although the team did not specifically evaluate the night-eating syndrome, their results showed that 67% of those with AN-BP had disturbed circadian rhythm, potentially relevant to the night-eating syndrome.
Although the sample size was small, the results highlight the possible impact of vomiting and the duration of AN on impaired sleep quality.

What Can An Avatar Reveal About Body Image in AN?

Vol. 28 / No. 5  
In a German study, beauty was in the attitude, not the eye, of the beholder.
Although viewed as central to AN, body image disturbance is still not that well understood. A team of researchers in Germany and Switzerland have turned to three-dimension (3D) technology to better define the effects of image disorders by studying 24 women in AN and 24 control patients (Psychol Med. 2017. doi:10.1017/S00332917172008).
The researchers sought to examine whether women with AN overestimate their weight or are merely more sensitive to weight changes compared to normal controls. Next, they wanted answer the question, how do women with AN and controls differ in regard to their desired bodies? A third question was whether an individual’s estimated body size or desired body size correlated with eating disorder symptoms or actual body size? The researchers also invited the study participants back for a repeat of the experiment– but now in 2D–to evaluate how robust individuals’ answer another question, “How robust are our findings on own body size estimation and body size?”
The research team then used 3D body scans to create virtual reality 3D bodies (avatars) for each study participant. The avatars were varied through a range of ±20% of the participants’ weights. They also used a stereoscopic virtual reality life-size stereo display that allowed for realistic weight manipulations of the photo-realistic avatars.
At the start of the experimental session, each woman was informed that based on her body scan, an exact model and more or less manipulated models of her body had been generated. The process was described to participants as akin to inflating, then deflating a balloon. When the subject saw different versions of her body she was asked to decide whether the version was exactly her body or if it had been manipulated. In the first experiment, participants estimated the size of their own body and indicated their desired body size. In the second experiment, participants estimated the size of the weight and shape of an avatar that was altered to have a different identity but the same size and shape.
Distorted attitudes, not visual distortions, were the key
The authors’ results were interesting in that they contradict a widespread assumption that patients with AN overestimate their body weight because of visual distortions. Instead, based on their results, the authors feel attitudinal components are distorted in AN; in reality, the data suggest that if anything people with AN underestimated their weights. Thus, affected individuals feel underweight bodies are desirable and attractive. As a result, the authors recommend that clinical interventions be aimed at helping patients with AN change their attitude about “desired” weight and accept their bodies at a healthy weight.

Orthorexia Nervosa and Anorexia Nervosa: Similar, But Distinctly Different

Vol. 28 / No. 5  

A focus on food but differences by culture, and quality and quantity of food.
An individual with orthorexia nervosa (ON) is nearly religious about eating only healthy and “pure” foods, and is fixated upon healthy eating behavior. He or she may not be obsessed with “the perfect diet,” but with achieving an ideal weight. This might mean avoiding fats, sugar, or salt, or any foods suspected of containing artificial colors, flavors, or preservatives. While orthorexia is neithert officially an eating disorder nor recognized in the DSM-5, it does share some features with anorexia nervosa.
Dr. Anna Brytec-Matera and her colleagues at the SWPS University of Social Sciences and Humanities, Katowice, Poland (BMC Psychiatry. 2017; 15:252) recently designed a study to assess orthorexic behaviors, eating disorder pathology, and body image attitudes to find possible evidence of orthorexia among 52 women with eating disorders. The authors’ assessment included using the Eating Attitudes Test-26 (EAT-26) to identify ED symptoms, and the Polish version of the ORTO-15. The ORTO-15 is designed to assess AN symptoms, including obsessive attitudes toward choosing, buying, preparing, and consuming “healthy” foods. Attitudes toward body image were measured with the Polish version of the Multidimensional Body-Self Relations Questionnaire, or MBSRQ. The MBSRQ uses 8 subscales to measure factors such as feelings of attractiveness, fat anxiety, dieting and eating restraint, for example.
Two distinct groups were identified
Latent class analysis (LCA) identified two groups of eating disorders patients. The first group had a lower level of disordered eating and more orthorexic symptoms, while in the second group, who reported higher levels of eating disorders, orthorexic behaviors were less common. The authors noted that eating-related disturbances are suggested to be risk factors for orthorexia, and that the reverse is also true. One unexpected result, according to the authors, was identifying a group of clinically diagnosed ED patients without typical ED symptoms assessed by the EAT-26. One possible explanation for this might be related to the fact that the EAT-26 is a self-report questionnaire, and ED patients might have chosen to omit information. The authors hypothesized that some patients may have low scores on the EAT-26 and high scores on the ORTO-15 because they may “mistake” their symptoms for healthy behaviors.
Dr. Brytek-Matera and colleagues noted that their study was a small pilot trial, and it was smaller than usually recommended for LCA, which might limit the reproducibility of results. Also, they did not gather information about any comorbid psychiatric diagnoses. Nonetheless, results suggest interesting and complex relationships between ARFID, orthorexia, and EDs.

Distorted Body Image and Misperception of Pain

Vol. 28 / No. 5  

Perceptions of pain and body image dissatisfaction were correlated in patients with AN and BN.
The many consequences of body image are clear to those who work in the field of eating disorders. However, disturbances of body image can also be associated with disturbed perceptions of pain, according to the results of a recent sturdy from the Czech Republic (J Pain Res. 2017; 10:1677).
Dr. Anna Yamamotova and psychologists at Charles University, Prague, examined the associations between perception of body image, body dissatisfaction, and pain perception in a group of 61 women inpatients with eating disorders (31 with AN and 30 with BN) and 30 age-matched healthy control women. All the inpatients were tested during their first week in the hospital. Forty of the patients were taking psychiatric medications at the time of the study; most commonly selective serotonin reuptake inhibitors.
Heat sensitivity was measured using a heat analgesia meter applied to the finger; participants withdrew the finger as soon as they began to feel pain. To avoid any injury, a timer was set for 10 seconds. The pain threshold was measured on the dorsal aspect of the right index, middle, and ring fingers.
All subjects then filled out a series of questionnaires. The Body Attitude Test (BAT) measures body image disturbances among women with eating disorders using 3 subscales: negative appreciation of one’s body, lack of familiarity with one’s body, and general body dissatisfaction. Body image perception and dissatisfaction with one’s own body were measured with Anamorphic Micro Software; Anamorphic Micro is a computerized image assessment program that allows the examiner to distort body image by up to 100%. Using the program, the examiner is able to widen or to narrow the photograph of the patient’s body.
A photograph taken of each patient standing in front of a plain white wall was enlarged or narrowed using the computer software. Patients were first asked to adjust each photograph so that it matched what they judged to be their real appearance. Then the patient was asked to adjust the modified image to correspond to how she would like to look.
As the authors had originally hypothesized, patients with AN and BN had similarly higher pain thresholds than did the controls. Not surprisingly, results from the BAT showed that patients with AN and BN were more dissatisfied with their bodies than were the control women. Both patient groups overestimated their body size (123% in BN patients and 130% in AN patients). Body perception did not correlate with pain sensitivity among those with AN or BN.
These results demonstrate some of the complex relationships that exist between ED cognitive variables and physical health.

In Search of Effective Treatment for BED

Vol. 28 / No. 5  

An important guideline is to stick to established protocols, according to a leading researcher.
Binge-eating disorder (BED) is now recognized as the most common eating disorder, affecting 3.5% of women and 2.0% of men. BED is three times more common than BN and AN combined, and more often diagnosed than breast cancer, HIV, and schizophrenia.
In a recent essay, Carlos Grilo, PhD, of Yale University School of Medicine, New Haven, CT, noted that all current approaches to treating patients with BED can be improved (J Clin Psychiatry. 2017; 78:20). Dr. Grilo writes that since only one-third to one-half of patients with BED seem to be helped by psychological and behavioral treatment, other ways must be found to help these patients.
The most common psychological and behavioral treatment interventions for BED, cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT), do not lead to weight loss. Behavioral weight loss (BWL) interventions achieve good outcomes plus modest short-term weight loss. What about adding pharmacotherapy to CBT in the treatment plan? According to Dr. Grilo, this seemingly logical approach has generally failed thus far. Results of controlled trials testing combination therapy have thus far been unclear. When medications are added to CBT or behavioral only modest improvement is reported.
The value of manualized treatments
Dr. Grilo recommends adhering to manualized protocols when using psychological and behavioral treatments for BED. Despite the temptation to integrate treatment based on individual clinical judgments, especially with challenging patients, research shows that evidence-based ED protocols can achieve excellent results.
Predicting outcome
A variety of patient characteristics, such as age, sex, ethnicity/race, and eating disorder psychopathology, have failed to be reliable predictors or moderators of outcome. However, as Dr. Grilo reports, early non-response to treatment has reliably predicted poor outcomes in several psychological approaches and medication trials as well. The patient who responds rapidly has predictably better chances for a good long-term outcome regardless of the individual treatment approach.
Dr. Grilo notes that early lack of response that is not associated with specific patient characteristics or severity of BED, “is a strong signal to clinicians to consider trying alternative treatments” (J Clin Psychiatry. 2017; 78:7). He further contends that clinicians should be trained to provide patients with BED with evidence-based treatments and suggests greater attention to predictors of response.