Do Eating Disorders in Parents Predict Eating Disorders in Their Children? Two studies revealed a definite link between parents and daughters.

Familial aggregation refers to occurrence of a given trait shared by members of a family. Two groups of researchers have recently published papers that expand our knowledge about the familial nature of eating disorders. 

Swedish research team members led by Dr. H. Bould used a subset of the Stockholm Youth Cohort born between 1984 and 1995 (286,232 individuals) to investigate whether parental eating disorders in parents predict the development of eating disorders in their children. A subset of these youths had a parent with an eating disorder, and the authors searched for any diagnosis of an eating disorder in their offspring. The diagnosis had to be made by a specialist clinician or inferred from an appointment at a specialist eating disorder clinic (Acta Psychiatr Scand. 2015; January 9. doi: 10.1111/acps.12389 [Epub ahead of print]. A final study sample of 158,697 (55.4%) cases were included.

The results showed that a parental eating disorder (affecting either parent) was associated with eating disorders in their female children. Due to the small number of cases, no conclusions could be drawn about risk for male children. 

Nationwide study of family aggregation and risk of AN over three generations

A second study also showed evidence of family aggregation and specific risk for AN. In a nationwide population sample, Hans-Christoph Steinhausen, MD, PhD, Alborg University Hospital, Alborg Denmark, and Swiss and Danish investigators conducted a study that explored how often AN and co-morbid disorders occurred in affected families compared with control families (In J Eat Disord. 2015; 48:1). Cases and controls were observed for long periods—the maximum was 40 years. For the case-probands, the mean observation time was 15.35 years. The data set contained 2,370 case-probands with AN identified through the Danish Psychiatric Central Research Registry and 7,035 controls.

The main finding of this second study was that AN occurred more often in relatives of case probands than in controls. AN was not seen in fathers of ill probands.

Taken together, these two papers expand what we know about eating disorders in families. They are both broadly representative cohorts (one, in fact, is a nationwide study). Critically, they are longitudinal, which helps to eliminate recall biases.

Eating Disorders Review

Gender-based Differences in Attitudes toward Eating Disorders Findings from a survey may have practical application in public information campaigns.

Eating disorders are commonly seen as a “woman’s illness,” and in the U.S. and Europe, people with eating disorders are often blamed for being ill, at least somewhat in contrast to patients with schizophrenia and mood disorders. Only a few researchers have examined the impact of gender on attitudes toward eating disorders.
There has been some evidence that gender does not impact knowledge about eating disorders, but perhaps men appear more stigmatizing.

A group of German researchers decided to test public attitudes toward eating disorders and to determine if there were any differences in attitude by gender. Dr. Anna Christin Makowski and a group at the University Medical Centre, Hamburg, Germany, used data from telephone interviews with men and women to examine attitudes about people with eating disorders (Eat Behav. 2015; 16:78). The interviewers used vignettes with typical signs and symptoms suggestive of AN and BN or depression or schizophrenia. The patient’s gender in the vignettes for depression and schizophrenia were varied, while those of patients with AN or BN were female. The interviewers measured causal attribution, emotion reactions, and social distance (in the social distance portion of the survey, for example, the respondents indicated, via a Likert-like scale, whether they would recommend the person for a job, or as a caregiver for a child). 

The interviews revealed some interesting gender-dependent differences in attitudes toward AN. Women were more likely than men to state that AN could be caused by sexual abuse during childhood. Men more often attributed AN to an individual having a weak will. The women respondents tended to associate BN with weak willpower. The authors found a potentially important effect wherein the belief that BN is self-inflicted (translation: the individual with BN has a “weak will”) and was linked to a greater desire for social distance among female respondents. 

Also of potential importance, among males attributing BN to a biogenetic cause (“brain disease”) was the finding that this was a significant predictor for men to distance themselves socially from women with BN. The authors note that this is an important finding because it highlights that endorsing a possible cause for eating disorders as something inherent can actually be detrimental. In AN, an earlier study showed that having a biogenetic cause for an eating disorder reduces blaming. 

In the case of AN, fear emerged as a significant predictor of a desire for social distance among female respondents, while males’ desire for social distance was associated with anger. The respondents distanced themselves far less from females afflicted by eating disorders than from persons with schizophrenia or depression.

How the findings might be used to reduce stigma

The authors argue that their results can inform stigma reduction effects. For campaigns aimed at women, the authors suggest that messages that emphasize the person over the diagnosis, and not using stereotypes, can be effective. For information campaigns aimed at male audiences, messages that emphasize social inclusion and recovery-oriented messages would be most effective. 

Eating Disorders Review

Brain Research Reveals New Hope for Patients with Anorexia Nervosa Preliminary studies show brain anomalies in AN diminish with weight rehabilitation.

It has been clear for some time that brain volume is diminished in people with AN, and some studies suggest it may be reversible. Until recently, neuroscientists studying the effects of anorexia nervosa (AN) on the brain were hampered by an inability to measure cortical structure anomalies well enough to fully define the changes. Now researchers from the Translational Developmental Neuroscience Lab at University Hospital Carl Gustav Carus, Dresden, Germany, have reported that widespread thinning of gray matter in the cortex of the brain that is seen in acutely ill adolescent patients can be completely reversed with successful weight rehabilitation (Biol Psychiatry. 2014; doi:10.1016).

Dr. Stefan Ehrlich and the Dresden researchers used structural magnetic resonance imaging (MRI) to study a large sample of both acutely ill and long-term recovered patients with AN. Newer techniques allowed for extremely precise measurement of cortical gray matter. 

Forty female patients underwent MRI scanning within 4 days after they were admitted to specialized eating disorder clinics and again following successful therapy with complete restoration to normal weight, eating behavior, and return of menstruation. Structural MRI data were also obtained among 34 recovered patients after long-term weight restoration and an equal number of age-matched healthy control subjects. Dr. Ehrlich’s group reported that the magnitude of cortical gray matter thinning in acute AN was similar, comparable to that typically seen in Alzheimer’s disease, and significant thinning of the cortical gray matter was seen over 85% of the cortical surface. Severity of low weight did not correlate with cortical thinning but there also was a strong negative correlation between drive for thinness and gray matter volume/thickness in extrastriate regions that play a role in body perception.

The authors concluded that the results show that structural brain anomalies in AN are primarily the result of malnutrition and are not likely to reflect premorbid trait markers or permanent scars.

Eating Disorders Review

Detecting Eating Disorders in Men and Women Athletes Identifying athletes at risk may require gender-specific tests.

Much research has examined disordered eating in athletes, but this work has mostly focused on women. The model of the female athlete triad (energy intake deficiency with or without disordered eating, menstrual disturbances, and bone loss) has been widely applied and found to be helpful for identifying women athletes at risk for an eating disorder. Theoretically, male athletes should also have a higher-than-normal risk for disordered eating because of the emphasis on body weight, shape, and size to successfully compete in individual sports. Thus, it might be assumed that similar traits would dispose male athletes to disordered eating. However, when researchers looked at 5 personality and psychological variables in male athletes—perfectionism, self-esteem, optimism, reasons for exercise, and concern about appearance—none of the variables significantly predicted disordered eating (Eat Behav. 2014; 15:615).

The researchers, led by Nick Galli at the University of Utah in Salt Lake City, theorized that pressure from society and sports to “look like” or “have an athletic appearance,” such as being lean and muscular, may lead to disordered eating. This was true in one study of female collegiate athletes who exercised to become more physically attractive, and also increased the likelihood that they would have symptoms of disordered eating patterns (Eat Disord. 2009; 17:302). The same emphasis on and concern with appearance might lead male collegiate athletes to become more dissatisfied with the size and shape of their bodies, a known risk for developing bulimic symptoms (Psychol Bull. 2002;128:125). 

A study group of 203 male athletes from three NCAA Division 1 colleges in the Mountain West, Southwest, and Midwest participated in the study. The men had a mean age of 20 years and a mean body mass index (BMI, mg/kg²) of 27.51. All were participants in 16 varsity sports ranging from football to wrestling. Most (roughly 75%) were classified as “ballgame” athletes, followed by “power,” “endurance,” “technical,” “aesthetic,” and “weight-dependent” (n=2) athletes. All completed a series of self-report questionnaires, including the 50-item Questionnaire for Eating Disorder Diagnosis (Q-EDD), the Multi-dimensional Perfectionism Scale, the Life Orientation Test-Revised, the Reasons for Exercise Inventory, and the Appearance Orientation Scale.

Nearly 20% of men showed symptoms of disordered eating

One-hundred and sixty-four of the male athletes (80.8%) were asymptomatic on the Q-EDD; and 39 (19.2%) were symptomatic. None met the Q-EDD cutoff for having an eating disorder. Personality and psychological variables could not significantly predict the male athletes’ Q-EDD grouping. These findings are in stark contrast to the research with female athletes, where, for example in one study that used psychological and personality predictors, 79.4% of the female athletes were correctly classified as either having or not having disordered eating patterns (Eat Disord. 2009; 17:320).

The authors concluded that risk variables need to be studied separately by gender to verify risk for disordered eating and eating disorders. Also, they feel a more helpful approach to measuring risk would be to measure variables that might be more relevant to male athletes, such as fear of stigmatization, low social support, and need for social approval, and to focus on other disordered eating patterns (drive for muscularity, drive for leanness, and anabolic steroid use).

Eating Disorders Review

Compulsory Treatment for Anorexia Nervosa Studies address difficult decisions in this area of continual debate.

Anorexia nervosa (AN) is, at times, addressed with compulsory treatment. Compulsory treatment has been somewhat controversial, but published evidence suggests there are benefits from it (Br J Psychiatry. 1999; 175:147). However, that particular article suggested that, after 5 years, mortality was increased in those receiving compulsory treatment compared to those receiving voluntary treatment. This is perhaps not surprising, but it is disappointing; one would hope that compulsory treatment might ameliorate long-term risks associated with AN, which are certainly high (and are well known to include mortality). 

In a recent article, Ward and colleagues reported on the roughly 20-year outcome of 81 participants (patients in the same study described in 1994 by Ramsey) compared to 81 matched patients receiving similar treatment (Int J Eat Disord. 2014; Dec 26. doi: 10.1002/eat.22377). Mortality over 20 years was examined using a national death register. The results showed that there were 12 deaths in the whole sample in the first 5 years, and that 15 more deaths occurred in the next 15 years. The overall standardized mortality ratio (the ratio of observed deaths in the study population to the expected number of deaths, based on age, gender, and ethnicity) after 25 years was 3.1. In other words, people with AN in this study were about three times more likely to have died than were people in the general population without AN. However, there were no significant differences in SMR between the compulsory and voluntary treatment patients.

In discussing the results, the authors state, “The findings of this study do not support the hypothesis that compulsory treatment itself has an effect on the longer-term mortality rate, including, as far as the evidence goes, that attributed to suicide.” This certainly is true regarding the concern sometimes raised that compulsory treatment might be associated with increased risk for suicide. In fact, given that mortality appeared elevated at five years, one might wonder if the opposite is true: that there may be long-term mortality reducing benefits of compulsory treatments in individuals with AN severe enough to warrant that compulsory treatment. 

Searching the databases for more information 

To provide a broad overview of research in this area, Isis F.F.M. Elzakkers, MD, and colleagues at Altrecht Medical Institute, Zeist, The Netherlands, searched articles in three large electronic databases (PubMed, Psychinfo, and Scopus) from the 1800s to April 2014 for studies on compulsory treatment for AN. The researchers hoped to find the frequency of hospitalization, the outcome, the risk factors, and finally feedback from AN patients who had undergone compulsory treatment (Int J Eat Disord. 2014; 47:845). 

Epidemiology and outcome

The authors found that compulsory treatment rates ranged from 1.5% to 11.6% of inpatients detained under the Mental Health Act (United Kingdom). They reported finding no “high-quality” data from the U.S. In one report, 28 AN patients out of 170 treated were legally committed over the course of 7 years (1991-1998) at the University of Iowa. In contrast, in an Australian study, 28% of persons admitted for treatment were treated compulsorily (Am J Psychiatry. 2000; 157:1806). 

Only 5 studies provided data on compulsory treatment, while two also had outcome and follow-up data. In one large study by Watson and colleagues, body mass index (BMI, kg/m²) at admission was relatively high in both the voluntary and compulsory groups (18.4 and 17.4, respectively), but they note that this was a diagnostically mixed group. When data from all 5 studies were analyzed, the authors found that patients in the compulsory treatment group had more severe symptoms of AN and other comorbidities (more previous admissions, more instances of self-harm, more common history of abuse, higher levels of depression, and longer duration of illness). Compulsory hospital stays were longer and weights at discharge were similar for both the voluntarily and compulsory treated groups. 

Dr. Elzakkers and colleagues report that little is known about the longer-term effects of compulsory treatment. Limited data suggest compulsory treatment may be associated with a tendency toward better outcome at one year. In addition, when they analyzed risk factors for compulsory treatment, the authors discovered that a higher severity or complexity of illness resulted in a higher likelihood of compulsory treatment.

How patients view compulsory treatment

Two qualitative studies have gathered patient feedback on compulsory treatment. When Tan et al. studied the attitudes of patients and parents toward compulsory treatment (Int J Law Psychiatry. 2003; 26:627 and 2010; 33:13), most patients reported that compulsory treatment was “self-evidently” the right thing to do because “no one was allowed to die from AN.” Many patients who had received compulsory treatment were grateful afterward, and many believed in retrospect that at extremely low weights they had impaired decision-making. 

More data are needed

The authors believe that long-term studies including at least 5 years of follow-up will be needed to gain a better view of the benefit of compulsory treatment for these patients. Results of such studies may also help clarify the fundamental psychological mechanisms underlying mental capacity, and help provide some guidelines for clinicians faced with the difficult decision of ordering compulsory hospitalization for this challenging population.