Q&A: Endocrine Problems Among Men with AN

Vol. 28 / No. 5 — Eating Disorders Review

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 — Eating Disorders Review

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 — Eating Disorders Review

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 — Eating Disorders Review

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 — Eating Disorders Review

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 — Eating Disorders Review

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 — Eating Disorders Review

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.

A Web-based Program Aimed at Overcoming Resistance to Treatment

Vol. 28 / No. 5 — Eating Disorders Review

One challenge includes surmounting a multitude of barriers.

About a third of adult outpatients in the United Kingdom who are referred to specialist eating disorder services never appear for their first appointment. Researchers are now experimenting with a new Web-based program designed to improve pretreatment attendance at outpatient services in the UK (JMIR Res Protoc 2017; 6:e146).

In what is believed to be the first internet program to address this problem, Dr. Sarah Muir and colleagues at Bournemouth University, Poole, Dorset Healthcare University NHS Foundation Trust, UK, and two other universities have designed a patient intervention program, “MotivATE.” In the UK, after individuals seek help for an eating disorder, their primary care physicians usually refer them to a specialist eating disorder service for an initial evaluation. Among the reasons that individuals do not take the next step are stigma about the disorder, a misperception that treatment isn’t needed, fear of change, and anticipated cost, having had an ED for a long time, laxative abuse, and symptoms of comorbid psychopathology. The authors’ literature review added other patient barriers, including preconceived notions of what treatment would entail, mistrust of health professionals in general, and even fear of abandonment by family and significant others.

The team first used intervention mapping (a protocol for developing theory-based and evidence-based health promotion programs) and a person-based approach, followed by a needs assessment and program development. Before they could design the program, the authors turned to people who had experienced an ED and conducted “think-aloud” interviews to understand beliefs about the relevance, acceptability, and the utility of their intervention program. To do this, they recruited volunteers from a university population and a local ED-focused charity.

The authors report that the MotivATE program attempts to increase attendance rates by helping individuals foster personal intrinsic motivation and increased self-sufficiency while at the same time addressing negative beliefs and expectations about the program. Another element involves determining the stage of change for an individual: pre-contemplation, contemplation, or preparation for change.

The website itself was viewed as “bright,” “cheerful,” and “calming.” It also enables users to read stories about others’ experiences with their eating disorders, features quizzes about change, and offers the visitor a chance to request personal advice and information.

An ongoing controlled trial will provide more answers

The authors are currently conducting a randomized controlled trial to measure the program’s impact. They also have had positive comments from service users and service staff, according to Dr. Muir. Despite their positive feedback thus far, the authors are still concerned about an essential key unknown: Will people register for MotivATE, and then go a step further to find care?

Approaches such as these may eventually fulfill a vital role in the process of help-seeking for ED.

UPDATE: Age and Gender Can Affect EDs over Time

Vol. 28 / No. 5 — Eating Disorders Review

Do people “age out” of eating disorders as they near mid-life, and if so are there discernable differences between the sexes? At the ICED meeting in Prague, Tiffany A. Brown, PhD, of the University of California, San Diego, and colleagues at Florida State University and Dartmouth College shared the results of a 30-year longitudinal study of body weight, perceptions of weight, dieting and symptoms of disordered eating in an initial group of 900 men and women followed from their 20s through their 50s. At the 30-year follow-up, 441 women and 179 men were still in the study.

The researchers found distinct differences in the course of EDs by gender and by age as well. From their 20s through their 40s, women were more likely than men to have an eating disorder, but by age 50, there was no difference between the genders. Drive for thinness also changed over time: it decreased among women but increased among men. In addition, the investigators found that bulimia nervosa deceased more slowly over time among men.

Weight status, perception of one’s weight, and dieting also took different paths over time among men and women. For the women in the study, their weight increased, but their focus on their weight decreased from ages 20 to 30, and then increased once more during the years from 30 to 50. Dieting frequency also decreased as women aged, up to age 40, but then increased from 40 to 50. Among men, weight, focus on weight, and dieting frequency increased over time. The impact of dieting frequency on drive for thinness decreased with time for both genders, but happened more quickly among men.

So, do people age out of EDs as they approach mid-life? According to the authors, most long-term studies have shown that most ED patients recover with age. However, they also reported that the incidence of EDs is currently increasing in men and women older than 45. ED diagnoses made in early adulthood remain prevalent in later adulthood for men as well as women. And, despite the increase in dieting frequency reported from age 40 to 50, there were no parallel increases in eating pathology.

Dr. Brown and her colleagues believe that current risk models for men and women with EDs need to be refined to account for developmental trajectories in which the dramatic gender differences seen in late adolescence diminish with time.

Taking a New Approach to Diagnosis and Treatment of EDs

Vol. 28 / No. 5 — Eating Disorders Review

At the 2017 International Conference on Eating Disorders (ICED) Conference in Prague early in June, eating disorders experts shared innovative approaches to better access to treatment, challenged some longstanding tenents about patient care, and presented new data about improving ways to measure atypical eating disorders.

A Global Approach to Psychological Care

Keynote speaker Dr. Vikram Patel, Director of the Department of Global Health and Social Medicine, Harvard Medical School, and Director of Socorro Village, Bardez-Goa, India, described two innovative programs designed to address alcoholism and depression in remote sections of India. Dr. Patel and his colleagues developed and used local resources to overcome the lack of psychologic care in geographically challenging areas. Although Dr. Patel is not an eating disorders specialist, he told the audience that he hoped “to infect your community with new ideas from other disciplines to confront and address health inequalities with every tool at our disposal.”

Dr. Patel noted that innovations and technologic advances are helping clinicians to reimagine what mental healthcare can look like. The field of eating disorders has been at the forefront of a number of those innovations, he said. Dr. Patel told the audience that it is a scandal that virtually no one in the lower or middle income levels in India has access to psychological treatment. The two main barriers are a lack of specialists and a gap between reality and the way most people in the lower income levels view disorders such as depression and anxiety. Many don’t regard mental health problems as unusual. This is a second barrier to care, he said.

Dr. Patel then described two innovative programs that are bridging the gap between lack of access to care and patients with psychological health needs. Brief psychological treatment is delivered by lay counselors trained in primary care treatment for depression and alcoholism (the Healthy Activity Program, or HAP) and the Counselling for Alcohol Problems, or CAP. In a controlled study, CAP was provided to 188 men. When Dr. Patel and colleagues evaluated their results after 3 months, CAP delivered by the lay counselors was more effective for harmful drinking than was usual care alone (Lancet online, January 14, 2017). The CAP program had strong effects upon abstinence and remission rates, but no effect on other alcohol-related outcomes.

The HAP program is specialist community model using primary-level workers (PHWs) who work with men with depression. Aides are trained to provide community support and treatment for persons with severe mental disorders. About 8 years ago, working with the Wellcome Trust, Dr. Patel set up a program, Premium, which he said was inspired by leading figures in the ED field, including his mentor, Dr. Christopher Fairburn. The theory behind Premium was to devise a method of scalable psychological treatment.

Dr. Patel said he and others initially mistakenly thought that Western mental therapies wouldn’t work in remote areas of India but would first need to be adapted for the local population. One realization was that the adaptation needed was not changing fundamental diagnostic and treatment approaches, but instead improving access to care. Thus, treatment was not so much cross-cultural but cross-social classes.

Dr. Patel credited the eating disorders field for being a leader in the forefront of using techniques such as guided self-help, self-help manuals, and web-centered training to reach patients. He told the audience that his hope is that lessons for global mental health and shared goals mean improving health for all people, everywhere, and the hope that specialists will learn from one another across varied fields of knowledge. Thus, he said, the key is not to change the fundamentals, but to change access to care.

Atypical Eating Disorders: Overlooked and Misunderstood

In a wild-card plenary session, “Atypical Eating Disorders: Addressing the Overlooked and Misunderstood,” four ED experts shared clinical and neurobiological research that is better defining Avoidant/Restrictive Food Intake Disorder, or ARFID. New ways of looking at atypical eating disorders, coupled with new data from brain imaging are changing approaches to diagnosing and treating atypical eating disorders. A strong case was made for avoiding the traditional approach of fitting the patient to an adult description of an eating disorder such as AN.

Viewing ARFID through the Eyes of Patients and Parents

Richard E. Kreipe, Elizabeth R. McNerney Professor of Pediatrics at the University of Rochester (NY) Medical Center, told the audience that, just as Dr. Bryan Lask reported more than 18 years before, presentations of EDs among children and adolescents don’t fit neatly into adult descriptions of those disorders. Instead, Dr. Kreipe challenged clinicians to try to see things from the patient’s and parents’ perspectives.

Symptoms reported by patients are real and not imaginary, he said. Dr. Kreipe stressed the value of assuming that parents of a child with an eating disorder are doing the best they can, and also not to automatically assume that reported symptoms in a child are “just part of his or her eating disorder” or that symptoms “are just the disorder talking.” Also, he noted, ARFID can continue into adulthood, and it may only be in midlife that adults realize they have had ARFID for many years.

Dr. Kreipe said that ED specialists are realizing that symptoms often attributable to psychological problems may have origins in physiological disorders such as swallowing problems, disrupted neural circuits, or to non-eating-disorder-related problems, such as autism spectrum disorders. He urged clinicians to expand their professional contacts to other specialties, “to go beyond our understanding.” He added, “We can realize that other areas of science can inform what we are seeing as an emotional disorder.” He also urged the audience to expand the circle of professionals they work with. For example, one promising area in ARFID research has come from interventions in autism spectrum disorders, he said.

Finding a More Precise Way to Measure Eating Disorders

Kamryn T. Eddy, PhD, Co-director of the Eating Disorders Clinical and Research Program, Massachusetts General Hospital, and Assistant Professor of Psychiatry at Harvard Medical School, Boston, described preliminary results from neurobiological studies that are helping researchers more precisely define and differentiate ARFID from eating disorders such as AN.

Dr. Eddy told the audience that clinicians should heed signs, not just symptoms, when approaching suspected cases of ARFID because a divergent biology may underlie AN and ARFID. Preliminary results from two studies have shown two distinct patterns. First, high food motivation, defined as hunger and reward, along with control, and thin-internalization are implicated in adolescent AN. In contrast, low-weight ARFID patients have low motivation for food and thin-ideal internalization is absent. She said a new direction in the diagnosis and treatment of ARFID involves the neurobiology of low appetite levels, sensory sensitivity, and phobic anxiety.

Early results from two ongoing studies

Dr. Eddy also shared some preliminary results of her team’s cross-sectional study of AN patients. In the first study, there are data for 34 females with AN and 25 healthy control patients. All the young subjects are being studied with brain scans at baseline, 9 months, and then at 18 months.

Using functional magnetic resonance (fMRI) scans, Dr. Eddy and colleagues compared patient reactions to images of high-calorie food, low-calorie food, and static objects among patients with AN and control subjects. The expectation was that AN patients would show robust reactions to high-calorie foods that could be seen in increased activity in the insula, amygdala, and orbital frontal cortex, a region of homeostatic and hedonic food motivation. As expected, there was increased reaction to high-calorie foods. But, if there was increased reaction to high-calorie foods, why weren’t the AN patients eating? The researchers also found higher signals in cognitive control centers in the anterior cingulate cortex and dorsolateral prefrontal cortex. Among patients with binge-purge type AN, the signals from the cognitive control centers were even higher. When tested, AN patients had higher-than-normal levels of the orexigenic hormone ghrelin. No such increases were seen in the control subjects.

The researchers are also evaluating restrictive eating among ARFID patients in an ongoing NIH R01 study aimed at recruiting 100 ARFID patients and 50 healthy controls, who will be followed for 2 years. The subjects are child and adolescent females and males aged 10 to 22 years. Thus far, data are available for 7 ARFID patients.

Dr. Eddy noted that the very preliminary results are showing that AN patients have very different patterns on brain scans than do youths with ARFID. Children with ARFID have hypoactivation of the insula and low levels of ghrelin, levels closer to those of the healthy controls. “There is a divergent biology between ARFID and AN,” she said. She also noted that such clinical data can be used to validate the patients’ experiences and can also reduce stigma. Preliminary findings are indicating hypoactivation in appetite neural circuitry (the anterior insula) in ARFID patients vs. controls.

Dr. Eddy also commented that clinicians often tend to rely on symptoms, which are subject to patient minimization and denial. She also briefly described the NIH RDoC Matrix, and ways in which this newer approach is improving diagnosis of eating disorders and ARFID. She and her colleagues have identified possible candidate signs in AN. For example, AN patients have high neural activation in homeostatic and hedonic food motivation circuitry, high ghrelin levels, implicit biases toward thinness and weight-shape control, and preference for larger delayed rewards over smaller immediate rewards. Another candidate sign for AN was high neural activation in cognitive control regions of the brain.

The group’s fMRI scans also showed that the pattern of hyperactivation in the insula shows greater hunger and food reward in patients who binge/purge versus restrictors. She found that orexigenic ghrelin levels are higher in patients with AN than in controls and these levels do not differ among restrictors and binge/purge patients. Restrictors and those with binge-purge type AN have thin-ideal internalization. Those with restricting-type AN show a preference for larger delayed rather than smaller immediate rewards.

In contrast, ARFID patients had low neural activation in homeostatic and hedonic food motivation circuitry in the brain, low ghrelin levels, and high brain-derived neurotrophic factor (BDNF) levels. Unlike patients with AN, ARFID patients have no implicit biases toward thinness and weight-shape control. They also have a preference for smaller immediate rewards, not larger, delayed rewards.

Dr. Eddy pointed out that longitudinal studies will help shed light on the state versus trait aspects of signs, and will help reconcile adolescent and adult findings. Psychoeducation can validate patient reports in ARFID and AN, which will reduce stigma and help motivate patients and caregivers as well. Few clinicians have an MRI scanner immediately nearby, she said, but the hope is that results of ongoing longitudinal studies of ARFID will give clinicians more accessible signs of the disorder.

Never Too Old for an Eating Disorder

Hans W. Hoek, MD, PhD, of Columbia University Mailman School of Public Health, and Director of the psychiatric residency program and chair of the Parnassia Bavo Academy at the Parnassia Bavo Psychiatric Institute, The Hague, highlighted groups of ED patients who are often overlooked and misunderstood, including males, non-Caucasians, and older women.

Dr. Hoek first reminded the audience of the gradual evolution of knowledge about EDs. With each decade, our understanding of EDs has been clarified, he said. For example, in the 1980s it was believed that there was a sudden epidemic of eating disorders; then in the 1990s, there was a belief that EDs were just female disorders. In the early 2000s, there was a belief that only westerners were affected by EDs. Then, in the 2010s it was believed that EDs were a disorder of young people only.

He advised clinicians to remember that eating disorders also occur in older persons. For example, in one Austrian study, Mangweth-Matzek et al. (Int J Eat Disord. 2014; 47:320) reported a prevalence of 4.6% of eating disorders in a group of 715 women 40 to 60 years of age. While none of the women currently could be diagnosed with AN, 1.4% had BN, 1.5% had BED, and 1.7% had EDNOS. In a more recent study (Int J Eat Disord. 2017; 50:793), there was a prevalence of EDs of 3.6% in a group of 342 women 65 to 94 years of age. The prevalence in 5658 women aged 40 to 50 years in a study in the United Kingdom was also 3.6% (BMC Med. 2017; 15:12). Dr. Hoek pointed out that EDs are still overlooked in older persons and new-onset AN is rare among older women. And, as for EDs in older men, prevalence rates have ranged from 0.02% to 1.5%, he said. In one questionnaire-based study of 470 Austrian men, the incidence of ED symptoms was 6.8% (Int J Eat Disord. 2016; 49:953).

BED and Other Specified Feeding or Eating Disorder (OSFED) are common among older women, he said. Sadly, Dr. Hoek noted, very few of these women receive treatment during their lifespan. He added, “What is also now known is that there is a higher risk of developing an eating disorder during times of life transition, such as adolescence, menopause or andropause, times when age-related changes can affect self-worth and body acceptance, and can also produce medical issues.”

Improving Understanding and Treatment of Atypical Presentations of EDs 

The final speaker on the panel, Pamela Keel, PhD, Professor of Psychology at Florida State University, Tallahassee, explored ways in which atypical presentations of eating disorders can be better understood and treated. She also spotlighted the RDoC project (http://www.nimh.nih.gov/research-funding/rdoc/nimh-research-domain-criteria-rdoc.shtml ), which integrates many levels of information, from genomics to self-reports.

Dr. Keel said that in sociodemographic groups who are subjected to the greatest pressure to adhere to a thin ideal in obesogenic environments, EDs will be characterized by an intense fear of fatness, and this psychopathology must be understood and treated. However, such fears are not meaningful in other sociodemographic groups not preoccupied by weight and shape. Instead, a patient’s distress may center on choking (ARFID), gastrointestinal symptoms (AN in non-Western cultures) or inability to control eating (BED), all situations that are meaningful to an individual within their cultural context.

Dr. Keel echoed the contribution of key clinical skills that Dr. Kreipe had stressed earlier, including understanding heuristics (mental “rules of thumb” based on experience) and biases, and listening to patients because their symptoms are real, not imaginary. She said, “When we require patients to conform to an experience of illness they do not have, we misunderstand them.” She also pointed out ways that heuristics can influence the way EDs are viewed. For example, when young and very thin women restrict their food because they wish to be thin, clinicians may only detect AN in those who fit the stereotype. BED is also a good example of this trend, she said. An example of this is when a clinician does not emphasize the stereotype of preoccupation with weight loss and fear of fat, it becomes clear that BED affects proportionately more men, a proportionately older population, and more ethnic/minorities. ARFID affects proportionately more boys and a proportionally younger population.

Dr. Keel reiterated that “We see eating disorders in all racial, ethnic, gender, age, and socioeconomic groups. No one is immune, and no two people have exactly the same eating disorder,” she added. Finally, Dr. Keel said, “We face several challenges in eliminating these debilitating illnesses, and some of these challenges are internally imposed.”

One Negative Effect of Weight Restoration among Men

Vol. 28 / No. 4 — Eating Disorders Review

In one study, short-term weight gains led to abnormal adipose tissue deposits in the abdomen.

Men recovering from anorexia nervosa (AN) may regain weight in an unhealthy way, according to a team of Italian researchers. In the first study to assess body composition in men with AN and how this changes with final weight restoration, Marwan El Ghoch, MD, and colleagues at Villa Garda Hospital, Verona, Italy, found that short-term weight restoration resulted in a pattern of abnormal central adiposity (Int J Eat Disord. 2017; doi:10.1022/eat.22721).

The researchers used dual-energy x-ray absorptiometry (DXA) to measure body composition in 10 men before and after complete weight restoration and in a control group of 10 healthy men matched by age and the AN patients’ post-treatment body mass index (BMI, kg/m2).

Treatment involved an adapted intensive form of enhanced cognitive behavioral therapy (CBT-E) for 13 weeks, followed by 7 weeks of CBT-E treatment given in a day hospital. During the early weeks of the program, patients work with a dietician until their BMI reaches 18.5. The program incrementally increases daily energy intake from 1500 to 3000 kcal. Once the patient’s BMI reaches 19.0, dietary intake is adjusted so hus body weight remains stable within a 2-kg window. Men whose medical conditions remained stable also had twice-weekly physical exercise sessions led by a physiotherapist. During these sessions, patients performed calisthenics to restore muscle strength and flexibility and to improve posture; aerobic exercises were used to help improve cardiovascular health.

Three patterns emerged with weight gain

The researchers reported three notable changes as the patients regained their body weight. First, the men appeared to have lost proportionately larger amounts of adipose tissue in their arms and legs than in their trunks. Second, as expected, the men with AN had lower BMIs, total lean mass scores, and fat mass scores before treatment than did their healthy peers (not surprisingly).

Finally, after short-term weight restoration, the men with AN had gained more body fat in their midsection in contrast to the healthy age-matched men. Dr. El Ghoch noted that his group had reported the same pattern of change in body composition with weight restoration in an earlier study of women with AN.

Examining Patients’ Capacity to Consent to Treatment

Vol. 28 / No. 4 — Eating Disorders Review

Patients with diminished mental ability respond more poorly in treatment.

Many genetic, psychosocial, and interpersonal factors work against treatment success in patients with anorexia nervosa (AN). These patients are often very reluctant to enter treatment, and impaired decision-making could further complicate this situation. According to a group in the Netherlands, people with AN with diminished mental capacity appear to do even less well in treatment and have poorer ability to make decisions than do patients without mental health problems. This does not improve with weight restoration (B J Psych Open. 2017; 3: 147. doi:10.1192/bjpo.bp.116.003905).

Isis F.M. Elzakkers, MD, and colleagues at the Eating Disorders Unit, Altrecht Mental Institute, Zeist, The Netherlands, examined decisional capacity at baseline and 1 and 2 years later. The Dutch group designed a longitudinal study of 70 adult female patients with severe AN. At baseline, psychiatrists established mental capacity, and clinical and neuropsychological data (especially regarding decision-making capacity) were collected. Then, after one and two years, clinical and neuropsychological tests were repeated, and admission and remission rates recalculated.

Participants completed the Eating Disorder Examination Questionnaire (EDEQ) and their body mass index (BMI, kg/m2) was established. The participant’s’ medical record provided information about admissions, treatments, and social functioning. Full remission was defined as weight in the normal range (BMI: 18.5 to 25.0), resumption of menses, and having no disabling anorectic cognitions. Clinicians with ED treatment experience used the MacArthur Competence Assessment Tool-Treatment (MacCAT-T), a semi-structured interview, to determine the level of mental capacity to consent to treatment. The Iowa Gambling Task (IGT) was also used to further assess each individual’s decision-making capacity.

One year later

After a year, 56 of the original group of 70 women (80%) agreed to continue on in the study, and at 2 years, 50 (71%) took part. At 1 year, 82% of the original group was still in treatment. After 2 years, 48 women, or 69%, were still receiving regular care. Only one participant in this study was held under the Mental Health Act at baseline, not due to his eating disorder but to comorbid alcohol dependence. One patient died of AN-related complications; a second patient died after the second follow-up. Both patients had been judged to have diminished mental capacity to consent to treatment at baseline, and both had BMIs below 15 kg/m2.

Mobile Apps Show Promise for Treatment among Young Patients

Vol. 28 / No. 4 — Eating Disorders Review

Little evidence yet, but benefits stem from easier access to care.

It seems like a natural step—using mobile phone software applications (“apps”) designed for children and adolescents with mental health problems. Certainly, the technology is widely available, since in 2017 most children and teens have access to mobile phones. In one study, the authors reported that 72% of children aged 0 to 11, and 96% of those 12 to 17 years of age had their own cell phones (J Med Internet Res. 2013; 15: e: 120; doi:10.2196/jmir.2600).

When a team of researchers from the University of Bath and Oxford Health National Health Service Foundation Trust, Keynsham, UK, did an extensive literature review of mobile phone studies, only 24 publications qualified to be included in their final review (J Med Internet Res. 2017; 19:e176). The authors also found a nearly nonexistent evidence base for the use of such apps, especially among adolescents.

Rebecca Grist, PhD, and her colleagues reported that the 24 publications they examined in the final phase of their study utilized a total of 15 apps, 2 of which could be downloaded. For the rest, 2 small randomized trials and one case study did not demonstrate any significant effect on intended health outcomes. None of 6 articles reviewing the content of 6 apps for children and adolescents, including those with eating or body image disorders, had been evaluated in a research context. The authors found that the majority of the health-oriented apps cited lacked adequate source information, and many also lacked privacy policies.

A promising approach despite few evidence-based studies

The advantages of mobile devices include their constant availability, anonymity for the user, low cost, and the ability for information to reach across most geographical barriers. Limited evidence exists to support apps for depression (Mobiletype) and OCD (Mayo Clinic Anxiety Coach). One app designed to improve body image and self-esteem (Pretty), was tested in a community sample of 206 girls 12 to 18 years of age (Veldhuis, doctoral dissertation; http://research.vu.nl/ws/portafiles/portal/1125682). The study involved use of Pretty and a similar app in a comparison group. Pretty asked users to rate the weight status of pictured models, whereas the comparison mobile app asked neutral questions about a famous singing duo. No significant differences were seen between the very different apps on measures of self-esteem or body satisfaction. Neither app improved body satisfaction levels, although significant improvements in self-esteem appeared after using either mobile app.

Despite the current lack of evidence for apps being helpful for users with mental health issues, the authors believe apps have a bright future and are particularly well suited for adolescents, most of whom are familiar with and regularly use the technology. Clearly, the mental health field will track broader society in a continued rapid evolution toward all sorts of technology-assisted treatments

A Screening Tool for Binge Eating Disorder

Vol. 28 / No. 4 — Eating Disorders Review

 7-point screening tool helps raise awareness of BED among clinicians.

Although it’s now the most common eating disorder, BED wasn’t formally recognized until the DSM-5 was published in 2013. Under-diagnosis of BED is believed to be relatively common. In an earlier survey testing physicians’ knowledge about binge eating and treatment recommendations for obesity treatment, more than 40% of physicians responded that they never screened or assessed patients for possible underlying binge-eating (Int J Eat Disord. 2004; 35:348).

One answer, according to the results of a recent study, may be use of the 7–point Binge Eating Disorder Screener (BEDS-7) in clinical practice (Prim Care Companion CNS Disord. 2017; Jun 29; 19(3). doi: 10.4088/PCC.16m02075). The BEDS-7 questionnaire contains items to examine eating a patient’s eating patterns and behaviors during the past 3 months. In contrast to screening tools such as the Eating Disorder Assessment for DSM-5 and the Eating Disorder Screen for Primary Care, the BEDS-7 only assesses BED. (For a sample of the BEDS-7, see: www.bingeeatingdisorder.com/hcp/media/BingeEatingDisorder_Screener_Apr16.pdf)

A test in 2 waves

Barry K. Hermann, MD, and colleagues tested the BEDS-7 in two study waves. Web-based surveys were administered at two time points to randomly selected primary care physicians serving adults and psychiatrists. In the first wave, an introduction to a downloadable version of the BEDS-7 and an invitation to use it in clinical practice was sent to 550 primary care physicians and psychiatrists. Of this group, 517 physicians consented to be re-contacted.

The authors found that most physician used the BEDS-7 for 1 to 4 patients (primary care physicians, 39.5%; psychiatrists, 56.3%), or in 5 to 9 patients (26.3% of primary care physicians and 21.9% of psychiatrists, respectively). The screening tool encouraged clinicians to do further tests for BED. Clinicians reported that the most important use of the BEDS-7 was for identifying patients with BED and encouraging or initiating discussions about binge eating. The most common reason primary care physicians and psychiatrists gave for not using the BED-7 was “forgetting that it was available.”

An easy-to- use tool that stimulates discussion

Most of the physicians, primary care physicians, and psychiatrists acknowledged the importance of being up-to- date on BED, and they noted that the screening test was valuable and easy to use. From wave 1 to wave 2, clinicians reported gaining significantly increased knowledge about BED. Perhaps not surprisingly, confidence in diagnosing and in treating patients with BED was significantly higher among psychiatrists than among the primary care physicians. Most respondents rated the BEDS-7 as very or somewhat valuable and easy to use.

One limitation to this tool is that it only assesses BED. Nonetheless, it could be useful for identifying patients with undiagnosed binge eating and for stimulating discussions with patients about the disorder and its symptoms.