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Unraveling Resistance to Change after Weight Is Restored

courtesy of eating disorders review

Clues emerged in a feedback experiment among AN patients and controls.

It is a challenging question: Why do many patients with anorexia nervosa (AN) continue to restrict their calories after their weight is restored and many of their psychiatric symptoms have improved? One possible reason, according to Karin Foerde, PhD and Joanna E. Steinglass, MD of Columbia University, is that AN patients may experience reduced learning from feedback or reinforcement. In their recent study, the same pattern was not seen among healthy controls (Int J Eat Disord. 2017; 50:415).

The researchers wanted to explore why reward processing among AN patients differs from that of normal control patients, and why learning from feedback is not effective. To do so, Drs. Foerde and Steinglass studied patients between 16 and 45 years of age who had DSM-5 diagnoses of AN-restrictive or binge-purge subtype AN (36 patients; 35 females and 1 male). All the subjects were inpatients at the New York State Psychiatric Institute, and were compared with 26 healthy controls (24 females, 2 males). The two groups did not differ in age, educational level, gender, ethnicity, or general cognitive functioning.

After 2 sessions of an association task, individuals with AN showed poorer learning from feedback in comparison with the healthy controls; this pattern was reported both before and after weight was restored. The reduction in feedback learning was associated with eating disorder psychopathology and suggested by the association with some eating disorder symptom severity scales and illness duration—but not with body mass index, or BMI. However, AN patients could generalize from what they had learned, just as the healthy controls did. Their psychological symptoms did get better with weight restoration treatment, but feedback learning did not. Both groups were well matched on global cognition, including IQ, working memory, and attention.

Although the authors’ study involved a behavioral task and no direct studies of the brain, their results were consistent with those of studies that have evaluated various forms of striatal-based learning among AN patients. (J Cognitive Neuroscience (2003;Myers et al. 2013). This suggested the possibility of frontal striatal abnormalities in AN patients. In a small study conducted in 2003, Lawrence et al. used a learning task sensitive to striatal function and a memory test sensitive to medial temporal lobe damage in a small group of AN patients tested while underweight. Foerde and Steinglass found this same pattern in their study after weight was regained.

Maladaptative behaviors may arise during development

If feedback learning is compromised in AN, how could this be related to the maladaptive behavior in AN? One answer, according to the authors, might be maladaptive behaviors established during a developmental “window” of learning in adolescence. Maladaptive eating behaviors and accelerated learning are most common during adolescence. Or, AN may affect neurocognitive processes so that developmental learning worsens the longer a person is ill, making it ever harder to counteract maladaptive behavior.

Decreased learning from feedback may also be important to the patient’s response to treatment. According to the authors, problems with feedback learning seen at baseline, without regard to how and when the behavior is acquired, and that are associated with failure to respond to treatment, could be a marker for a more chronic course of illness.

What Prompts Change in Younger Anorexia Nervosa Patients?

courtesy of eating disorders review

Measuring reasons for change among teens was not easy.

Two major roadblocks to change among patients with anorexia nervosa (AN) include ambivalence toward changing eating behaviors, and denial of the illness. Attempts to measure motivation to change among patients with eating disorders have led to development of instruments such as the Readiness and Motivation Interview (Int J Eat Disord. 2002; 46:755) and the Attitudes Towards Change in Eating Disorders Scale (ACTA) (Int J Eat Disord. 2000; 28:387; Acta Esp Psiquiatr. 2003; 31:111). A 20-item questionnaire, the Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ), examines three key factors in motivation, weight gain, eating, shape and weight concerns, and ‘ego-alien aspects.’

Dr. Dagmar Paul and colleagues at the University Hospital of Psychiatry, Zurich, Switzerland, evaluated the German translation of the ANOSCQ among a Swiss-German sample of 92 teens with AN diagnosed by the International Classification of Diseases, Tenth Revision (ICD-10) criteria who were referred to the authors’ specialist eating disorders clinic. The researchers hypothesized that low coping capacity as well as low self-esteem could be linked to lower motivation to change patterns of disordered eating. The authors also explored whether motivation to change in AN patients is due to readiness to change, or if readiness to make changes should be regarded as only one of many other factors.

The mean body mass index (BMI, kg/m2) of the patient sample was 16.4 kg/m2, below the third percentile for age standards. The mean age of the 87 females and 9 males was 15.6 years; 84 had restricting type AN, while 8 had binge-purge type AN. All participants also were evaluated with the Eating Disorders Inventory (EDI-2), the Eating Attitudes Test (EAT), the Body Image Questionnaire (BIQ), the Self-related Cognitions Questionnaire, which measures self-esteem and self-awareness, and the Coping Across Situations Questionnaire (CASQ), which addresses coping in 4 problem areas: problems with school, parents, peers, and the opposite sex. Treatment outcome was defined as treatment satisfaction by the treating clinician, drop-out from treatment, and remission of AN (no longer fulfilling criteria for AN).

Changes at follow-up

At follow-up 9 months later, 66% of patients no longer met the criteria for AN, and of the remaining 30 patients, 20 had restrictive-type AN, 5 had binge-purge type AN, and 5 were diagnosed with atypical AN.

A negative correlation between ANOSCQ scores and BMI emerged: The authors’ findings indicated that BMI was inversely correlated to motivation to change, just as reported in earlier studies. Dr. Paul and his coauthors surmised that this might be due to the fact that young patients who are in the first phase of weight loss have not yet come face-to-face with the disadvantages of their illness, and thus are determined to lose even more weight. Their level of motivation to change is thus low. The study subjects had had AN for about 1 year; only 3.3% were in the action state, and none in the maintenance state. This finding contrasted with earlier studies, in which 20.5% of patients were in action or maintenance states.

The authors concluded that while the ANSOCQ questionnaire was valid and consistent, it might be less useful for young patients in the early stages of AN. The authors pointed out that younger patients at an early stage of an eating disorder are less aware of the negative consequences of the illness, and therefore “experience most of the symptoms as rather ego-syntonic or may ignore ego-dystonic aspects.” There is a need to assess motivation more systematically to enhance therapeutic strategies in younger patients.

The Effects of Compulsive Exercise among Teens

courtesy of eating disorders review

A large longitudinal study targeted younger patients with EDs.

Information about the benefits of exercise abounds, including the many ways regular exercise can improve our health and life. Compulsive exercise, however, is a completely different matter, particularly for people with eating disorders. Approximately one in four teens with eating disorders uses compulsive exercise to lose weight or to improve appearance. A Swedish group recently examined whether teens show the same associations between compulsive exercise and problematic behaviors as do adults. In a second study, a British group analyzed a test for identifying compulsive exercise.

Does compulsive exercise differ in teens vs older groups?

Drs. Johanna Levallius, Christina Collin, and Andreas Birgegård, of Stockholm’s Karolinska Institute, evaluated how compulsive exercise relates to eating disorders diagnoses, symptoms, and outcome among teens. The authors hypothesized that patterns of compulsive exercise would be similar in teens and adults and also that such exercise would be associated with earlier onset of an ED, more symptoms, the presence of suicidality, negative perfectionism, hyperactivity, and overall poorer prognosis (J Eat Disord. 2017; 5:9 doi 10.1.1186/s40337-016-0129-8).

Using the Stepwise database, a nationwide Swedish clinical database of ED patients seeking treatment at specialized treatment centers, the authors identified 3,255 patients between 13 and 17 years of age, 95.7% of whom were girls. Age at onset of disease was defined from the patient’s own account of the first appearance of symptoms, and other data were collected from numerous questionnaires. This is the largest longitudinal study thus far to investigate the effect of compulsive exercise on adolescents with EDs.

The Eating Disorder Examination Questionnaire (EDEQ, adolescent version) provided information about denial of illness, and 31% of AN patients fell into this category. More than a third of the patients regularly used compulsive exercise (mean: 4 times a week) to moderate their weight. Patients with bulimia nervosa (BN) used compulsive exercise most often. Patients who compulsively exercised differed significantly from those who did not on several measures: restraint (as measured on the EDEQ), negative perfectionism, emotional distress, hyperactivity, and self-esteem. When “disease deniers” were taken out of the equation, the groups of non-compulsive and compulsive exercisers were much more similar. Compulsive exercise was not linked to increased risk of suicide.

At follow-up, the authors noted a degree of cross-over, so that most patients (69%) stopped using compulsive exercise as compensatory behavior. However, 17% of those who hadn’t used compulsive exercise before had now adopted the practice. Patients who stopped using compulsive exercise had a greater likelihood of remission compared to those who continued exercising compulsively.

Teenage boys: 1 in 3 used compulsive exercise

There were some data for teenage boys, too. Twenty-nine percent of the boys reported using compulsive exercise and did so for a mean of 4.1 times a week. As in the case of the girls, boys who compulsively exercised had significantly higher global EDEQ and restraint scores, and also reported more negative perfectionism, emotional distress, and hyperactivity than did the other boys. Depression affected 28% of the boys, and the prevalence was 41% among boys who used compulsive exercise. At the one-year follow-up point, 58% of the boys were in remission, and their initial use of compulsive exercise did not affect their prognosis.

For the girls, compulsive exercise was more common among those with BN and eating disorders not otherwise specified (EDNOS) than among those with AN. This was the same pattern seen in earlier studies of adult women (Int J Eat Disord. 2006; 39:45, Behav Res Ther. 2011; 49:85). Compared to studies of adults, adolescents who engaged in compulsive exercise did not have a worse prognosis than those who did not. At the one-year follow-up point, two-thirds of the teens who originally used compulsive exercise were no longer doing so, and the remission rate was similar for them as for teens who did not compulsively exercise (59% vs 56%, respectively).

The authors also cautioned against instructing ED patients to stop exercising–except during the acute phase of treatment. Instead, they suggested concentrating on teaching patients to eat and exercise for the right reasons.

Testing for compulsive exercise

Dr. Levallius and colleagues noted that while tests for CE have been largely lacking, British researchers have recently provided psychometric data on such a test, The Compulsive Exercise Test, among a group of 356 adult patients with EDs and 360 non-clinical controls (women 16 to 60 years of age). Patients and controls took the test and also completed the EDE-Q (J Eat Disord. 2016;4:22). Caroline Meyer, MD, and colleagues at the University of Warwick, Coventry, UK, noted that up to 85% of patients with disordered eating use compulsive exercise, and are unable to stop the practice despite understanding the possible consequences.

The Compulsive Exercise Test contains 24 self-report items designed to assess the cognitive, behavioral, and emotional features of compulsive exercise. A previous factor analysis yielded five subscales: avoidance and rule-driven behavior, weight control exercise, mood improvement, lack of exercise enjoyment, and exercise rigidity (Taronis et al, 2011). The current paper described efforts to confirm this factor structure and to look at the relationship of scores to ED psychopathology.

Among the study group, 25.9% of patients had AN, 31% had BN, 38% were diagnosed with EDNOS, and 5% had diagnoses of BED. The control group was recruited from a university campus, workplaces, and a sports club. Elite or sub-elite athletes were excluded. The authors reported that the clinical group scored significantly higher than the non-clinical group on 4 of the 5 main subscales and had significantly higher global scores. However, the mood improvement subscale scores did not differ, and there were no significant differences by age.

Dr. Meyer and colleagues note that while much more research on the CET is needed, the fact that excessive or driven exercise often predates the onset of an eating disorder suggests the CET might be a way to identify individuals at risk of developing an eating disorder.

Defining Compulsive Exercise

Compulsive exercise (also termed problematic exercise) describes a condition of weight and shape concern and a persistent continuation of exercise in order to: (a) mitigate guilt/negative affect if not exercising, and (b) to avoid perceived negative consequences of ‘stopping’ exercise (Eur Eat Disord Rev. 2011; 19:174).

Bone Loss Risk across the Anorexia Nervosa Spectrum

courtesy of eating disorders review

Higher current weight does not protect against a history of extreme food restriction.

Bone density (BMD) impairment and comorbid psychopathology can affect women on all points of the anorexia nervosa (AN) spectrum, not just those who are currently underweight and/or amenorrheic, according to the results of a recent study (Int J Eat Disord. 2017; 50:343).

Compared to the DSM-IV, the DSM-5 has relaxed some of the diagnostic criteria for AN. For example, the newer diagnostic criteria eliminate the requirement for amenorrhea, and loosen weight and psychological criteria. In addition, the guidelines add a new diagnosis of “atypical AN” for persons with psychological symptoms of AN but who aren’t at lower-than-normal weights.

Dr. Melanie Schorr and a group at the Massachusetts General Hospital and Harvard Medical School recently investigated if and how BMD is affected among women diagnosed with AN by the DSM-5, including those in the new category of atypical AN. This is the first study to directly compare bone density among groups all across the AN diagnostic spectrum and healthy controls.

The researchers studied 4 groups of premenopausal women ranging from 18 to 45 years of age: (1) 37 with diagnoses of AN from DSM-IV criteria but not DSM-5 criteria (DSM-IV AN group); (2) 33 with AN diagnosed with DSM-5 but not DSM-IV criteria (DSM-5 group); (3) 77 women with atypical AN (atypical AN group); and a comparison group of 21 healthy women (HC group). BMD and body composition were assessed for all the women through dual-energy x-ray absorptiometry (DXA) scans. Posteroanterior (PA) spine BMD, measured from lumbar vertebrae 1 through 4, was available for 166 of the 168 participants, and lateral spine BMD of the same 4 vertebrae was measured for 106 women. In addition, eating disorder psychopathology was assessed with a number of questionnaires, including the Eating Disorder Examination-Questionnaire (EDE-Q).

Higher weight and restoration of menses do not guarantee healthy BMD.

The authors also reported significant differences in body composition among the 4 groups. Mean percent fat mass was similarly low in women with DSM-IV and DSM-5 diagnoses of AN, higher in those with atypical AN, and highest in healthy women. As BMI falls, as was shown in all 4 groups, there was a concurrent loss of lean muscle mass as well because of extreme food restriction. Loss of lean muscle mass may also contribute to low BMD, according to the authors.

The authors’ data suggest that severe impairment of BMD can occur even among individuals at higher weights and those who have normal or regular menstrual periods. They also report that women with DSM-5 diagnoses of AN, even those at normal weights, and especially those with a history of low weight and/or amenorrhea, showed evidence of significant bone loss when compared with normal women. Even when they weren’t underweight, women with atypical AN and a history of low weight and/or amenorrhea had significantly lower mean PA spine BMD z-scores than did healthy women. Thus, being at a higher weight does not protect a former AN patient from low BMD when he or she has a history of low weight and/or amenorrhea.

Better understanding might be a motivating factor.

This is an important study for several reasons. First, Dr. Schorr and colleagues note that when patients understand that pathological food restriction can lead to loss of lean mass, not just fat mass, it may be motivation for change. This is especially true for women who fear they will only “get fat” as their weight is restored. Second, women with significant psychopathology and low body fat, low-weight women with DSM-5 diagnoses of AN, and normal-weight women with atypical AN and a history of low weight and/or amenorrhea are all candidates for DXA scanning. Third, this underscores the idea that in eating disorders, subthreshold does not equate to less severe.

BED and Somatic Illness: What Part Does Obesity Play?

courtesy of eating disorders review 

An important role for primary care physicians. 

Binge-eating disorder (BED) loves a crowd, a diverse crowd of physical comorbidities, that is. A range of comorbidities, including type 2 diabetes, obesity, autoimmune disease, and fibromyalgia, for example, have been previously reported with BED. University of North Carolina researchers recently sought to determine if medical comorbidities are more common among patients who present with BED and obesity.

Laura M. Thornton, PhD, and her colleagues in Chapel Hill, NC, used several Swedish population registries to identify individuals with BED treated as inpatients and outpatients from 1999 to 2009 (Int J Eat Disord. 2017; 50:58). Then, they used the Swedish National Patient Register to obtain information about somatic illnesses for all cases of eating disorders. Psychiatric comorbidity was modeled as the presence or absence of any lifetime psychiatric disorder or suicide-related intentional self-harm injury, and was used by the searchers as a covariate.

The overall sample included 9,350 persons (95% were females), and the average age was 29 years—96% were 18 years of age or older. The final study group included 850 individuals (39 males and 811 females) with BED.

A wide range of comorbidities are involved with BED 

BED was significantly associated with all types of diseases except genitourinary system disorders and congenital malformations. The strongest associations were with endocrine diseases, such as diabetes mellitus, and circulatory system disease. Obese patients with BED were more likely to have a lifetime history of respiratory, gastrointestinal, and dermatologic disorders than were individuals with BED without comorbid obesity. A link to the metabolic syndrome was suggested by the pattern of comorbidities. Thus, successfully treating binge eating might help prevent metabolic syndrome.

One improvement would be screening for binge eating at the primary care level

An important aspect of Dr. Thornton’s study is that it helped address the question of whether medical risks in people who are obese and have binge eating relate to BMI, binges, or both. The results linked obesity to increased risk for respiratory, gastrointestinal, and dermatologic disorders, but not other classes of illness, suggesting risk for some diseases in persons with BED, including metabolic syndrome, can’t be entirely attributed to the effects of obesity.

Their results also underscored the importance of referring people with BED who have somatic complaints for further evaluation, and also support screening for binge eating in primary care settings. According to the authors, because non-psychiatric clinicians may be the first clinical contact for patients, improving detection of BED in primary care settings could lead to quicker referrals and care.

A Healthy Exercise Prescription for ED Patients

reprinted courtesy of eating disorders review

In a keynote session, “Management and Therapeutic Use of Exercise in Eating Disorders Treatment,” Brian Cook, PhD, outlined an interdisciplinary approach to harness the power of exercise to heal the body amid the unique setting of eating disorders. With EDs, he said, the interdisciplinary approach includes psychology, physiology, and nutrition, which he described as a crucial part of successful treatment. Dr. Cook is Assistant Professor of Kinesiology at the California State University, Monterey Bay. [See “The Effects of Compulsive Exercise among Teens,” elsewhere in this issue.]

Compulsive Exercise

Two major questions concerning exercise in recovery include the appropriateness of exercise for clients and how to harness the healthful power of exercise to heal the body, he said. EDs are tough to handle, with the highest mortality rate of psychiatric illnesses, coupled with recidivism and secrecy, he added. However, he added, “We see a rising acceptance of exercise in certain eating disorders, especially binge-eating disorder, where the research, which is good, shows that exercise prevents relapse. The data for anorexia nervosa and bulimia nervosa are still emerging.”

Noting that there is so much push-back on including exercise as part of ED treatment protocols, Dr. Cook told the audience that ED professionals need to lay the groundwork for research, etiology, and therapy. Patients with eating disorders are often in a very bad state physiologically, and all too commonly linear thinking leads to excluding exercise in treatment, he said.

Last year Dr. Cook and colleagues performed a systematic literature review of guidelines for exercise in eating disorders treatment (Med Sci Sports Exerc. 2016; 48:1408). The group identified 11 core themes that have been successful when using exercise in ED treatment: (1) use of a team of relevant experts, (2) monitoring medical status, (3) screening for exercise-related psychopathology, (4) creating a written contract of how therapeutic exercise will be used, (5) including a psychoeducational component, (6) focusing on positive reinforcement, (7) creating a graded exercise program, (8) beginning with mild-intensity exercise, (9) tailoring the mode of exercise to the needs of the individual, (10) including a nutritional component, and (11) debriefing the patient after exercise sessions.

The Exercise Medicine Initiative

Dr. Cook also pointed to an important movement that can be used to better define the use of exercise among patients with eating disorders, the Exercise Medicine Initiative by the American College of Sports Medicine (ACSM). The group has established recommendations for pre-exercise health screening (Med Sci Sports Med. 2015; 48:579). The goal is to better identify individuals who need medical clearance before beginning an exercise program, including patients with clinically significant diseases (such as EDs) who would benefit from participating in a medically supervised exercise program.

Every day more technological devices make it more and more easy to sit and do nothing, he said, and the ACSM is working to help clinicians and patients understand exercise in an appropriate fashion, he said, adding that regularly assessing and treating exercise problems fits well with ED treatment. A team approach is a must for developing an exercise protocol, he said. The main thing is that clinicians can’t do this on their own, but instead need the help of other professionals. Professionals in physical therapy and nutrition, for example, have expertise that is essential to designing an appropriate exercise program. They can help determine if exercise is helping or hurting the patient and importantly when it is not useful for an individual with an eating disorder.

Some contraindications to exercise

Medical contraindications to exercise include dehydration, and other negative physiologic effects. However, he advised that, rather than concentrating on negatives, clinicians can help patients become aware of what their body is telling them, and that carefully designed exercise programs can be enjoyable and appropriate for ED patients.

Another point is to help patients imagine themselves as healthy, and to help them become aware of the signals the body is giving. For example, in many exercise programs, such as in yoga, an important aspect of the program is separating good pain from bad pain and improving body self-awareness. Identifying factors involved on overtraining is also important, and getting a patient to accept the negative effects of overtraining and to recognize warning signs of this are important. He recommends that a recovering ED patient start exercising at a slow pace. It is also helpful to draw attention to progress in other areas, such as improvement in body weight, and to tailor that to outcome.

Diabetes Type 1 and Eating Disorders

reprinted courtesy eating disorders review

Managing an eating disorder and type 1 diabetes mellitus (T1DM) is extremely challenging for clinicians and patients alike, Jennifer L. Gaudiani, MD, Founder and Medical Director of the Gaudiani Clinic, Denver, told the audience in her session, “Eating Disorders in Type 1 Diabetes.”

Puberty is the peak time for diagnosing both T1DM and eating disorders, Dr. Gaudiani said, noting that eating disorders or disordered eating affects as many as 30% of patients with T1DM. A major psychological risk factor is that while T1DM presents with initial weight loss, once blood glucose is regulated and weight is restored, the young patient may believe that “insulin makes me fat.” This can lead the patient to withhold or restrict her insulin to lose weight (diabulimia). Furthermore, Dr. Gaudiani said, the presence of both disorders causes a surge in mortality in these patients. For example, in a 10-year follow-up study (Nelsen et al, 2002), the death rate for those with AN alone was 2%, and for those with T1DM alone was 6.5%, but for those with AN and T1DM, the mortality rate rose to 38%. Concurrent diagnoses of an ED and T1DM confer a 5 times greater mortality rate than AN alone, Dr. Gaudiani added. In another 11-year study, she noted that patients with EDs and T1DM were 3.2 times more likely to die, and their lifespan was cut by 13 years, compared to patients who did not restrict insulin. In addition, comorbidities such as anxiety and personality and behavioral disorders abound in those with concurrent diagnoses of T1DM and eating disorders, she said.

Physical side effects

Edema and the fear of developing it is one of the greatest barriers to recovery and to patients resuming their insulin, Dr. Gaudiani added. Secondary aldosteronism is at work, and insulin itself causes resorption of water and salt in the renal tubule, causing refeeding edema. Clinicians can minimize this by using spironolactone, and making sure patients are forewarned about the signs of diabetic ketoacidosis, she said. The spectrum of new or worsening complications can include retinopathy, gastroparesis, neuropathy and/or neuritis, and vasovagal syncope. An additional problem occurs when hypoglycemia triggers binge eating.

A multidisciplinary team is needed.

Inpatient or residential treatment demands the help of a multidisciplinary team, including therapist, endocrinologist, dietitian/CDE a nurse, psychiatrist, and other medical specialists, as the patient progresses from full support to autonomy.

At first the staff monitors glucose and insulin, and then care is agreed upon by the staff and patient. A RN and the patient agree on the insulin dosage, and the patient then draws and administers her insulin under supervision. In time, patients can then gradually assume full responsibility for diabetes self-care. Dr. Gaudiani noted that team members should have experience with, or at least be knowledgeable about,T1DM and EDs. She added that the key to successful treatment is coordination of the treatment plan and communication about progress. Insulin dosage must be adjusted frequently, collaboratively, and incrementally, both up and down, she said. For outpatient care, patients must be willing to take their insulin to avoid diabetic ketoacidosis. As in inpatient care, outpatient care includes participation by numerous professionals, including school health personnel.

Should patients use an insulin pump? Dr. Gaudiani pointed out that studies have shown that insulin pump therapy achieved significantly lower glycated hemoglobin (A1c) levels with “fewer hypos and no weight gain”; it is also used successfully in TIDM patients with mental disorders. The pros include need for only one “stick” every 3 days; dosing is similar to using a cell phone; and there are fewer barriers to keeping insulin levels steady. The negatives about using an insulin pump therapy are that it is a “24/7 reminder of the presence of diabetes and can be a trigger in outpatient therapy if use of the pump was involved in earlier negative behaviors,” she said.