Q&A: Sleepless Nights and Purging

Vol. 28 / No. 6 — Eating Disorders Review

Q: I have a 21-year-old female patient who continually complains about lack of sleep. She was diagnosed with anorexia nervosa, binge-purge type (ANbp), about 3 years ago. She thinks that her lack of sleep might be making the binge-purging worse. Does disturbed sleep worsen purging? (LB, Palo Alto, CA)

A: This is certainly possible. Disrupted sleep is common among people with ED. Evidence for disrupted sleep in ED is clear, although most work has focused on night eating syndrome (Allison et al, Curr Psychiatry Rep. 2016; 18: 92). Disturbed sleep does appear to be common among patients with eating disorders. In one study of 549 college women, 30% of those with AN, BN, or BED, had significant trouble with insomnia, compared to 5% of the students overall.

According to a report from Kohnodai Hospital in Chiba, Japan, patients with binge-purge subtype AN have worse global sleep quality and more disturbed sleep than do anorexic patients with the restrictive form of the illness (ANr). This is the first study to focus on the role purging behaviors with eating disorders play in sleep quality. Dr. Tokusei Tanahashi, a psychosomatic medicine specialist, and his colleagues examined how purging relates to subjective sleep quality and sleep patterns, and the effect of disordered eating behavior on global sleep quality among women with both subtypes of AN (Biopsychosocial Medicine. 2017; 11:22). Dr. Tanahashi and his group also reported that in their earlier study of female outpatients with ANr and ANbp (Sleep Med. 2015; 16:S347), they found that patients with ANr or ANbp had a relatively high prevalence of sleep disturbances (15.8% and 70.8%, respectively).

In their current study, when the authors compared the two groups of patients, using the Japanese version of the Global Pittsburgh Sleep Quality Index (PQI-), the mean score of the ANbp type anorexic patients was significantly higher than that among the restrictive group. Sleep latency, habitual sleep efficiency, and daytime dysfunction of ANbp patients all were significantly greater in the ANbp group than in the ANr patients. Circadian rhythm was also more disrupted among the binge-purge group.

How might purging affect sleep? The authors speculate that any patients with habitual vomiting tend to binge-eat at night, due to the high rate of night-eating syndrome among persons with eating disorders. This factor might in turn delay the onset of sleep. This can take the form of a long delay before falling asleep, sometimes into the afternoon hours. Binge-eating/vomiting before bedtime might cause sudden electrolyte abnormalities and blood glucose variations, resulting in poorer quality of sleep. Patients may then stay up late eating but still wake early to accomplish their daily routine Another possible outcome would be sleeping too long because of illness related interference with their social life, leading to worse daytime function.

Importantly, sleep may normalize with weight restoration. El Ghoch and colleagues (Eur ED Review. 2016; 24:425) examined sleep patterns in 50 people with AN and 25 controls using wearable sleep monitors. People with AN had less sleep time and shorter sleep onset latency, and these both normalized with weight restoration. -SC

Television and Dysfunctional Eating in Teens

Vol. 28 / No. 6 — Eating Disorders Review2

One gender-related difference emerged in a study in southern Italy.

Adolescence can be a wondrous time of physical growth and exposure to new ideas and experiences, but it may also bring social aspects of everyday life that negatively affect body image. Environmental factors such as teasing by peers and family members and exposure to unattainable ideals of thinness are good examples.

Dr. Barbara Barcaccia and researchers at the University of Sapienza, Rome, and Boston College explored the possible influence of models portrayed on TV on adolescents. The authors sought to examine body image, uneasiness with one’s body, eating-disordered behavior, depression, and anxiety among a group of teens and young adults (Revista Brasileira de Psiquiatria. 2017; doi:10.1590/1516-4446-2016-2200, published online before print). The Italian researchers studied 301 teens 14-19 years of age who were recruited from 13 high schools in southern Italy. The teens filled out a series of questionnaires, including The Body Uneasiness Test (BUT) and the Eating Disorders Inventory-2. The BUT contains 71 questions about weight phobia, body image concerns, and worries about specific bodily parts and functions (Eat Weight Disord. 2006; 11:1). Sample statements include “I avoid mirrors” and “I compare my appearance with others.”

Responses differed by gender

One trend that emerged from the study was gender-based responses to media exposure, highlighting differences in susceptibility to body misperceptions among males and females. Just as reported in previous studies, drive for thinness was impacted more by media exposure in females than males. Perhaps sensitivity to media images helps explain differences in ED prevalence by gender. The authors noted that women do watch more entertainment and image-focused television programs than do men (Eat Behav. 2013. 14:441). They also pointed out that objectification theory states that in Western culture women are specifically objectified and their bodies used to measure self-worth. This then leads to a subconscious tendency for women to compare their body image to others to a greater extent than do men (Psychol Women Q. 1997. 21:173).

Another interesting finding in this study was that the extent to which males’ friends wished to physically resemble TV characters; this was the only statistically significant finding for the males in the study. The authors pondered various possible causes for this trend. While males and females are sensitive to the influence of their friends, in the Italian culture, according to the authors, boys and men interact socially to a greater extent than in other parts of the world.

The results also showed that women were more susceptible to ED behaviors, distorted perceptions of their bodies, and development of depression after exposure to mass media. In contrast, males were more susceptible to distorted perception of their bodies, state and trait anxiety, and depression through indirect comparisons to the mass media through their friends.

A Promising Agent for ED Patients with Severe Behavioral Problems

Vol. 28 / No. 6 — Eating Disorders Review3

A pilot study used an agent originally designed for patients with epilepsy.

Studies of medications such as SSRIs for individuals with eating disorders have focused on the ED, but many people have co-occurring pervasive severe affective and behavioral problems. A recent trial has offered hope for this subgroup of ED patients.

Some patients with bulimia nervosa (BN) and binge-purge type anorexia nervosa (ANbp) can have many bouts with loss of control eating and compensatory behaviors, such as self-induced vomiting, often with severe medical morbidity. Other comorbid behaviors can include substance abuse, impulsive behaviors such as shoplifting, and self-injury.

Dr. Mary Ellen Trunko and colleagues at the University of California, San Diego, recently reported the results of their pilot study evaluating use of the mood-stabilizing drug lamotrignine (Lamactal®) in a group of patients with ANbp and BN with a range of dysregulated behaviors who had not responded to antidepressants (BPD and Emotion Regulation. 2017; 4:21). The small study group included 9 women with AN or BN-spectrum eating disorders (14 started the trial but 5 did not complete 2 months, for various reasons). All the women were participating in dialectical behavior therapy (DBT) in partial hospital or intensive outpatient treatment settings. Their treatment included 10 hours per day, 6 days per week. As the women improved, they were able to step down to 6 hours of treatment a day and ultimately to 4 hours a day. All participants received a routine lamotrigine titration until a target dose of 100 to 300 mg per day was reached.

Their DBT program included weekly individual sessions, twice-weekly skills training groups using the DBT Skills Manual (Linehan M. DBT Skills Manual, second ed. Guilford Press, New York, 2008), group sessions, and skills coaching via telephone contact or text-messaging outside program hours. The women also underwent emotional and behavior assessments and were studied with a number of questionnaires, including the Eating Disorder Examination Questionnaire (EDEQ). All the DBT therapists met as a team once a week.

An improvement in symptoms was noted

All 9 women who completed the study reported reductions in dysregulated emotions and problems with impulse control. In general BEST and ZAN BPD ratings improved and lamotrignine was said to well-tolerated. One of the women stopped the medication because of a possible rash, a rare but potentially very serious side effect of lamotrigine.

The authors argued for a large-scale rigorous investigation of the drug, with and without DBT or other therapies. This would differ from most med trials in ED in that an inclusive rather than exclusive set of criteria would be used, resulting in a highly comorbid group (of the sort we often see in routine clinical care).

Some Surprising Genetic Findings for Individuals with Anorexia Nervosa

Vol. 28 / No. 6 — Eating Disorders Review

One discovery was a genetic basis for greater educational achievement.

We know there is an important genetic component to anorexia nervosa, but a recent study points in some surprising directions. This large study by Laramie Duncan, PhD, and colleagues (Am J Psychiatry. 2017; 174:850) not only suggests that AN can be partially heritable, but also that metabolic, weight-related, and inflammatory factors may be some of these inherited components.

A scan of the entire genome for links

In all, 3,495 participants with AN and 10,982 controls took part in this remarkably large study. A genome-wide associate scan was conducted to search the entire genome for links between AN and genetic markers. At least three major findings emerged. First, confirming results from previous studies, AN was shown to be partially inherited, with genes accounting for about 20% of the chance of developing the disorder. Second, there was a strong association between AN and the area on a chromosome near genes for diabetes mellitus and some autoimmune diseases. Third, people with AN had lower body mass indexes, lower insulin and glucose levels, and higher high-density lipid cholesterol levels than those without the disorder. Finally, individuals with AN had higher educational achievement. This is an interesting finding because in the past such accomplishments were assumed to be primarily related to family environment. This study suggests that higher achievements may in fact have a genetic basis.

These findings, if replicated, will greatly broaden our understanding of the phenomenon of AN, to include both metabolic and behavioral components of the disorder.

Self-Admission for Inpatient Treatment

Vol. 28 / No. 6 — Eating Disorders Review

A small study found areas that needed improvement for ED patients.

For more than a decade, selected patients with severe psychiatric illnesses, including eating disorders, have been able to admit themselves for inpatient treatment in several European countries (which differs markedly from practice in the US).

Eligible patients can typically admit themselves at will for 3 to 7 days, and may leave the service at any time. To be eligible, patients must maintain constant contact with the adult outpatient unit or day treatment unit. Another requirement is that they must have been treated at least one time in the adult inpatient ward during the past 3 years, and know the framework of and the routines and rules of the specific ward.

Swedish researcher Dr. Mattias Strand and colleagues wanted to examine patient experiences with self-admission during the process of starting a new self-admission program in an eating disorders service at the Stockholm Centre for Eating Disorders (BMC Psychiatry. 2017; 17:343). The Swedish researchers interviewed 16 patients in a self-admission program after 6 months, to learn about their experiences and to get suggestions for improving the program.

Some room for improvement

Most patients were generally satisfied with their experience, but they also had suggestions for improvements. One overarching issue was maintaining the balance between the positive effects of the patient’s sense of autonomy and the difficulties handling the freedom and responsibility involving in self-admission. Some patients were not always confident that they could use the increased accountability in a constructive way. An example of this was problems that arose during the process of reserving a bed in the inpatient center. Although the patient is responsible for checking on the availability of a bed and calling back to check on the status of a bed before admission, this was stressful and proved discouraging to some. Establishing a separate waiting list for the self-admission beds (usually 2 to a unit) was the solution. Other patients found staff rotations unsettling. Because their stay in the hospital was usually brief, they did not always work with the same staff members, and had no single regular contact person. Some felt there was not enough emphasis on long-term goals. One patient summed it up well by saying, “This thing about deciding a lot for yourself—perhaps you need to be a little careful about that because if you get to decide for yourself, very often it will be the illness talking.”

Some changes were made

The authors implemented several changes, including providing more thorough information about the rationale of self-admission and patient accountability. They also provided a single contact staff member for each self-admitted patient. Another very important addition was a thorough discussion of one major drawback of the program: the brief time of admission makes it unlikely that a patient can achieve any long-term treatment goals during a single stay. Instead, the authors stress that self-admissions should be viewed as booster opportunities or brief respites. Finally, according to the authors, patients with an eating disorder may be even more reluctant to seek help than other patients, and this needs to be addressed in the design of future self-admission programs.

This is an intriguing approach. For those with ED, one wonders if it will be highly effective in interrupting symptoms of binge eating and purging, or restricting, or if ultimately it will be too small a dose to be helpful.

A Better Way to Measure Body Composition?

Vol. 28 / No. 6 — Eating Disorders Review3

Measuring free fatty mass with BIA equations

Body weight and body mass index (BMI, kg/m2) are two major measurements used to establish body composition and degree of underweight or overweight. However, according to a group of Italian researchers, these gold standards turn to tin with severely malnourished patients, such as those with anorexia nervosa (AN). Dual energy x-ray absorptiometry (DXA) represents a gold standard but is not always available; BIA is more available but seen a less valid. Could better equations to calculate BIAS results help? (Nutr Clin. 2017; http://dx.doi.org/10.1016/ clnu.2017.07.016, published online).

One such technique uses DXA. Dr. Maurizio Marra and colleagues at Frederico II University, Naples, Italy, evaluated several BIA equations to determine how accurately they could estimate body composition among patients with AN. Their study group included 82 AN patients with restrictive-type disease (ANr) who were attending the outpatient clinic at the authors’ university. All underwent whole-body DXA scans with two x-ray beams at different energy levels to measure free fatty mass (FFM, or lean body mass plus bone mineral content) and fat mass (FM). BIA was performed and then various approaches to analyzing the results were examined.

Results: BIA measurements underestimated FFM

On average, all the BIA equations significantly underestimated DXA-derived FFM values. Overall, DXA was more accurate than BIA, which in turn gave a more accurate picture than BMI.   The authors underscore the need to develop disease specific methods for analyzing BIA results as a way to make them more useful.

Web-Based Aftercare for Women with Bulimia Nervosa

Vol. 28 / No. 6 — Eating Disorders Review

Early results were promising, but dropouts were a problem.

Response to treatment for BN is modest, but an important factor is that relapse is common (Psychosom Med. 2011; 73:270). To combat this, a group in Germany recently designed a 9-month manualized CBT Web-based aftercare program for women with BN (J Med Internet Res 2017; 19:e321, published online before print). This is one of the first studies designed to evaluate the efficacy of programs targeting maintenance or improvement of treatment gains achieved during inpatient treatment for BN.

Web-based interventions have several advantages over face-to-face interventions, according to Dr. Corinna Jacobi and her colleagues. Patients’ access to the Internet reduces barriers such as cost, availability of services, waiting time, transportation challenges, and stigma about having an eating disorder. The increased anonymity may also encourage individuals to seek help.

Dr. Jacobi and her fellow researchers conducted a randomized controlled trial of 253 women with DSM-IV diagnoses of BN. Over more than 4 years, patients were screened and recruited from 13 hospitals throughout Germany that offer inpatient treatment for eating disorders. Patients were eligible for the study if they were at least 17 years old and had reduced their binge-eating and compensatory behaviors by at least 50% compared to their levels at hospital admission. Participants were then randomized to treatment with the Internet program, “IN@,” or to treatment as usual.

The Web-based intervention, IN@, included information on eating behaviors and core bulimic symptoms, and advice about healthy exercise, body image, and self-esteem. In addition, the IN@ program included a monitoring log for bulimic symptoms and a personal diary. Three clinical psychologists specially trained in behavior therapy for EDs also provided individualized email feedback and up to 9 monthly real-time individual personal chats of about 1 hour per participant. Women in the treatment-as-usual group were also assessed at all follow-up points, and had the option to take part in any outpatient treatment programs offered by the individual hospitals. Assessments were made at admission, at discharge from the hospital, 9 months after admission, 9 months after the intervention, and 9 months after this. Because the study hospitals were scattered throughout Germany, and the patients returned home to different parts of the country, all interview assessments were done by telephone by trained assessors blinded to patient group assignments.

The authors reported that 15% of the women in the intervention program never logged onto the Internet site after being discharged. The remaining 107 women accessed at least half of the intervention content. Forty-seven women (37%) participated in at least one live chat.

Symptoms and program adherence at study’s end

In general, results were numerically better in the IN@ group, but many othercomparisons were not statistically significant. Binge-eating episodes increased significantly in both groups after discharge from the hospital. However, at the post-intervention follow-up, binge-eating episodes were 27% lower in the intervention group than in the treatment-as-usual group. At follow-up there was no difference between the two groups. At the post-intervention assessment, about 1 in 5 patients reported abstinence from binge eating and lack of compensatory behaviors during the prior 2 months, but the difference between the treatment groups was not significant.

As for the incidence of vomiting at the post-intervention point, it was 46% lower in the intervention group, a statistically significant difference. At follow-up, the frequency of episodes of all compensatory behaviors was 41% lower but the difference was no longer significant. The authors note that even though the intervention did not significantly affect abstinence, the results may have important clinical implications, namely that rates of vomiting in the intervention group were almost half of those among the treatment-as-usual group.

What could improve adherence to a Web-based CBT program? The authors suggest that future programs be directed at adapting interventions to help increase adherence and reduce dropouts because use of the website and live chats was modest.

Stigma and Discrimination Are Everyday Occurrences for Obese Patients

Vol. 29 / No. 1 — Eating Disorders Review

A problem that can also be found in healthcare settings.

Obese patients often are confronted by multiple forms of discrimination in daily life, according to the results of a recent study by L. Pearl, Thomas A. Wadden,  and their colleagues from the Center for Weight and Eating Disorders at the University of Pennsylvania, Philadelphia (Clin Obes. 2017;doi:10.1111/cob.12235). The authors assessed different reasons given for discrimination experienced by a racially diverse sample of individuals seeking treatment for obesity. Of the 122 individuals in the study, 66% were black, and the mean BMI was 38.5 ± 6.2 kg/m2.

The majority of the study participants reported experiencing at least one form of repeated discrimination, and 30% had experienced two or more types of discrimination. Discrimination by race and weight were the most common types of repeated, everyday discrimination. More than 80% of those who had been confronted with weight discrimination reported at least one other form of discrimination, usually due to their race (60%).  The authors called for further research to help understand how all forms of discrimination contribute to the health problems related to obesity.

Stigma and obesity

“In the field of public health, stigma is a known enemy,” Dr. Rebecca M. Puhl and Chelsea A. Heuer, MPH wrote in an earlier article (Am J Public Health. 2010; 100:109.). The authors, from the Rudd Center for Food Policy and Obesity, Yale University, New Haven, CT, found that stigma and discrimination toward the obese are pervasive and widespread in North America. After completing an extensive literature search, the authors concluded that weight stigma, often used in an attempt to reduce obesity or improve health, is actually counterproductive. Instead, of the time-honored method of shaming and blaming an individual for his or her weight, they argue that the emphasis should be on addressing weight stigma as a social justice issue and a priority in public health interventions.

According to the authors, one irony is that healthcare settings can also be a significant source of weight stigma (Obesity [Silver Spring] 2009; 17:941), which can undermine the chances for effective medical care. Some of the negative stereotypes and attitudes toward obese patients by healthcare providers and fitness professionals include personal views that obese patients are lazy, lack self-discipline, and are dishonest, unintelligent, and won’t comply with treatment.

Race-related vigilance toward obesity

University of Massachusetts researchers recently analyzed the impact of race-related vigilance on obesity risk. Race-related vigilance describes the concept of “preparation for and anticipation of discrimination.” This is a concept of considerable relevance because experiencing discrimination increases risk for medical problems (for example, the authors cite the finding of elevated blood pressure among those experiencing race-related discrimination in the CARDIA study).

In a group of 12,214 blacks who responded to the Reactions to Race module of the Behavioral Risk Factor Surveillance Survey (Obesity Science & Pract. 2017; doi:10.1002/osp4.42), obesity, Dr. R. L. Powell and colleagues found that 17% of those who responded to the survey reported thinking about their race more than once a day. Frequently thinking about one’s race was a risk factor for obesity among blacks participating in the study. The prevalence of obesity was higher among black women (41%) than among black men (32%), although a higher percentage of men (32%) than women (13%) reported thinking about race daily.

The authors note that the results of their study suggest that very high levels of race-related vigilance, both of explicit discrimination and implicit “micro-aggressions” (such as nonverbal, unconscious verbal or visual insults) contribute specifically to the high rates of obesity among black Americans.

Family-Based Therapy for Teens with Severe AN

Vol. 29 / No. 1 — Eating Disorders Review

The teen’s perception of family function was a key to treatment success.

Family-based therapy (FBT), the approach of choice for adolescents with anorexia nervosa (AN) being treated as outpatients, uses the family as the key agent during therapy.

In a recent study at the Sydney (Australia) Children’s Hospital Network and the University of Sydney, the adolescent patient’s view of the family and its function was critical to success of FBT (J Eat Disord. 2017; 5:55). Dr. Andrew Wallis and colleagues explored the relationship between family functioning, teen-parent attachment, and remission, as well as changes over time, for a group of adolescents with severe AN being treated with FTB.

The authors pointed out that while FBT works for most, it doesn’t work for everyone. Length of illness, prior hospitalizations, and older age, cannot be modified once treatment begins. In contrast, if family functioning could be modified during treatment, this might improve response (Eur Eat Disorders Rev. 2016; 24:43). Some positive elements in family function have been tied to the outcome in previous FBT studies—particularly positive relationships between parents and adolescents, parental warmth, and family cohesion, for example (J Fam Ther. 2005;2:104; J Ment Health. 2005;14:575). Better family organization and control early in treatment often predicts a good outcome from treatment. In contrast, a negative communication style, including critical comments, has the opposite effect.

The 57 teens were a subgroup from a previously reported randomized controlled trial by the authors that investigated the role of inpatient weight restoration prior to entry into outpatient FBT (Psychol Med. 2015; 45:415). Those participating in the original study had met DSM-IV criteria for AN of less than 3 years duration, and were medically unstable when admitted. Eligible subjects were then divided in to two treatment groups, either to medical stabilization or to minimum weight restoration before they went on to outpatient FBT.

A three-stage process helps parents take responsibility 

The study used type 3-stage FBT, in which parents initially take responsibility for their child’s weight gain and return to normal eating patterns, to reverse the starvation caused by AN. As treatment moves into its second and third phrases, responsibility for eating is slowly but surely handed back to the adolescent, helping him or her progress independently with food and normal adolescent life. The therapy team included three psychologists and a social worker.

The teens were assessed at baseline, at the 20th session of FBT, and 12 months after session 20. Remission outcome was defined as percent of expected body weight (%EBW) using Centers for Disease Control and Prevention growth charts, and EDE global scores. Family function and adolescent-parent attachment were evaluated with the Family Assessment Device and the Inventory of Parent and Peer Attachment. The Family Assessment Device is a self-report measure including 60 items divided into 7 subscales (problem solving, communication, roles, affective responsiveness, affective involvement, behavior control, and a general scale that measures family function). Just as its name implies, the Inventory of Parent and Peer Attachment is a 45-item questionnaire that seeks to probe the affective cognitive expectancies associated with the quality, rather than the categories, or attachment relationships between the young person and his or her mother and father.

The importance of the teen’s perception of family function

Teens who reported poorer general family functioning had more comorbid psychiatric features and were more likely to have binge-purge type AN. In contrast, better adolescent–reported family functioning was associated with higher adolescent self-esteem and stronger adolescent attachment to both parents

Few or no changes in the quality of the parent-teen relationship were reported during treatment or at follow-up.  No elements of mother-reported family functioning at the beginning of treatment were related to better outcome from FBT; however, higher levels of father-reported behavior control (for example, establishment of rules and expected behaviors) at the beginning of treatment were positively related to remission in the long term.

Dr. Wallis and colleagues stress the importance of family functioning for people receiving FBT, for the adolescent’s perception of family functioning at the beginning of treatment did predict remission. Teens who perceived better family communication and ability to solve problems were more likely to respond to FBT.

Driven Exercise and Its Connection to Purging Disorder

Vol. 29 / No. 1 — Eating Disorders Review

A study examines how those who use driven exercise to lose weight might fit into the ED spectrum.

The DSM-5 category of “Other Specified Feeding and Eating Disorders” includes disordered eating behaviors that are still being defined.  One of these, purging disorder (PD), is common and causes high levels of impairment and distress.

Janet Lydecker, Morgan Shea, and Carlos M. Grilo recently reported that individuals who regularly engage in compulsive and driven exercise to control their weight exhibit characteristics similar to people who use traditional purging behavior (laxative abuse or vomiting) to control their weight (Int J Eat Disord. 2017; doi:10.1002/eat.2281).

To investigate the use of driven exercise and weight control, the trio of researchers recruited 2,026 participants using Mechanical Turk, an online tool. The participants self-reported their current weight and height, which was used to calculate body mass index.  Participants also filled out a series of questionnaires, including a shortened version of the Eating Disorder Examination, the Godin Leisure Time Exercise Questionnaire, which records the frequency of physical activity across levels of intensity during a typical week, and the Patient Health Questionnaire-2, which assesses recent mood state. The participants were also categorized into several groups, those with regular compensatory driven exercise (297),  those who regularly used vomiting/laxatives (59), individuals with broadly defined AN (20), and those with no eating disordered behaviors (1, 658).

Higher levels of depression were identified among three groups

The authors reported that individuals who habitually used compensatory exercise, regular compensatory vomiting or laxative use, and those with diagnoses of AN had higher degrees of eating disorder psychopathology and physical activity than did those with no eating disorders. However, the groups did not significantly differ from one another on most domains. Those who used compensatory vomiting/laxatives and those with AN had higher levels of depression than did those with regularly compensatory driven exercise.

The authors’ study provides new information about driven exercise as a form of PD in the psychopathology of persons who regularly binge-purge and use other compensatory behaviors but do not binge-eat. In general, there was little or no evidence for the exercise group being less severely ill than the traditional PD or AN groups. This “makes it [driven exercise] an important behavioral feature of EDs to assess epidemiologically as well as in clinical studies with individual patients,” the authors remarked.

Is Disturbed Body Image a Component of BED?

Vol. 29 / No. 1 — Eating Disorders Review

In a small pilot study using an exposure-CBT technique, body image improved among overweight women with BED.

While body image disturbance is not an official criterion of the diagnosis of binge eating disorder (BED), it seems to be a naturally relevant part of the disorder.  To explore a possible connection between body image and BED, a pilot study combined exposure-based body image therapy with CBT that directly targeted image disturbances (J Eat Disord. 2017; 5:43). The authors believe it is the first randomized controlled trial to examine the effects of body image therapy on the cognitive-affective, behavioral, and perception of body image disturbance among overweight women diagnosed with BED.

As reported by Dr. Merle Lewer of Ruhr-Universität Bochum, Bochum, Germany, and colleagues at 3 other German universities, 34 overweight women with diagnoses of BED were randomized to a manualized body image therapy (15) or to a waiting-list control group (19). Just before and at the end of the study, all participants completed 3 self-report questionnaires: the Eating Disorder Inventory-2(subscales of Drive for Thinness, Bulimia, and Body Dissatisfaction), the Body Checking Questionnaire, and the Rosenberg Self-Esteem Scale.

A photo technique is used to distort image

After the questionnaires were completed, the researchers applied the Digital Photo Distortion Technique (Appetite. 2007; 49:467). First, a frontal view digital photo of each participant was taken with the participant standing before a white wall while wearing a standardized tight-fitting pink suit. Then, the photos were fed into the digital distortion system and were shown to each participant on a laptop. By pressing two arrow keys on the computer, the participants could adjust their photo to appear thinner or larger. They could correct or change the photo as they liked in response to three questions, “What do you really look like?” “What do you feel you look like?” and “What would you like to look like?”

Ten weekly CBT-body image sessions followed

CBT-body image therapy was conducted in an outpatient center at the Rohr Universität Bochum. During 10 weekly sessions, each about 90 minutes long, the women in the intervention group learned about the perceptive, cognitive-affective, and behavioral components that make up disturbed body image. Treatment was individualized for each participant, and each participant also had two special individualized sessions. Mirrors and video feedback were also used, with an emphasis upon helping each participant develop a realistic image of her body, using tasks to focus on positive body areas and to shift attention from negative body areas.  Additional exposure exercises were introduced, such as visiting a public swimming pool. Tasks aimed at enhancing potentially  rewarding body-related activities included dancing, visiting a sauna, or using a new personal care product such as body lotion. The last session was aimed at relapse prevention.

Improvement was noted after 10 sessions

At the end of the 10 sessions, there was general overall improvement in body image disturbances among the intervention group. This study adds to prior work supporting the exposure-CBT intervention technique in underweight and normal-weight females with eating and body image problems and shows it was effective in overweight women with BED as well. Two significant limitations were the small sample size and lack of a follow-up analysis. Some of the women in the control group had been on a waiting list for long-term individual therapy and had already started their own therapy by the time they became participants in the study. In addition, only female participants were included, to maintain the homogeneity of the group. The authors also reported that restrained eating was not affected by the intervention. This work highlights body image disturbance as a potential treatment target in BED.

Early Childhood Adversity and Development of EDs

Vol. 29 / No. 1 — Eating Disorders Review

Anorexia nervosa was the exception.

The pathways from childhood adversity, such as the breakup of the family or imprisonment of a family member, and later development of an eating disorder are still being debated. Results from a recent study from Denmark show that adversity during childhood does not equally increase the risk of all eating disorders (Int J Eat Disord. 2017; 50:1404).

Janne Tidselbak Larsen and colleagues reported that the risk of developing anorexia nervosa (AN) after childhood adversities was lower when there was a history of parental criminality and any parental adversity, and fell by 54% when a child was placed in a foster home. In contrast, any adversity, including family disruption, and psychiatric illness in either or both parents, was significantly associated with increased risk of developing bulimia nervosa (BN). The greatest risk of development of BN was associated with parental psychiatric illness. As the number of adversities rose, so did the risk for BN. Severe parental criminality was significantly tied to decreased risk of BN.

A large-scale data base was used for a cohort study

The population-based cohort study included all females born in Denmark to Danish-born parents between January 1, 1989 and December 31, 2007, excluding all children who had died or left Denmark before the age of 6. The Central Person Register is a unique personal identification number assigned to all Danish citizens and is used in all Danish National registries. The authors’ final study population included 495,244 Danish women.

The authors selected nine different types of childhood adversities that a child had been exposed to at least once during his or her first 6 years of life. These categories were: parental somatic illness (severe and chronic illness), residential instability (moving between Danish towns or cities more than once), parental psychiatric illness, severe parental criminality, parental disability, familial death (losing at least one parent or a full or half sibling), parental substance abuse disorder, and placement in a foster home or institution with or without parental consent. While the researchers had originally planned to include child abuse, they found they had too little data to include it and at the same time comply with Danish legislation protecting personally identifiable information.

Broadly speaking, some types of adversity diminished risk for AN, while exposure to adversity increased risk for BN and EDNOS. The authors do note that one limitation is that the adverse experiences studied occurred before age 5.  This factor helps clarify interpretation of cause but does not tell us about the impact of adversity in later childhood.

The authors believe this is the largest study yet to explore an association between various types of childhood adversities and eating disorders.

The Challenges of Involuntary Treatment for AN

Vol. 29 / No. 1 — Eating Disorders Review

Many barriers exist, including differing state regulations. 

What is the appropriate role for involuntary treatment in AN? Currently AN is the most lethal psychiatric illness, with a mortality rate of 6%. In addition, the effectiveness of treatment is mixed: only half of patients report full recovery, 30% reach partial recovery, and 20% remain severely ill. Despite the severity of the illness, clinicians may be reluctant to admit a patient for involuntary treatment. There are good reasons for this, as described by Dr. Patricia Westmoreland and colleagues at the Eating Recovery Center, Denver (J Am Acad Psychiatry Law. 2017; 45:419).

According to the authors, some AN patients need involuntary treatment, and clinicians have a professional obligation to help direct the patient to such life-saving treatment. One challenge is that patients with AN may be particularly credible witnesses who can effectively represent and defend their disordered eating behaviors. Many are careful not to imply in any way that that they wish to die from their illness.

Another surprising element about involuntary treatment is that clinicians are likely to encounter opposition from the family as well as the patient. Family members may be angry that their daughter or son is forced to endure involuntary admission, and their anger is directed at the treating psychiatrist.  And, if the treating physician chooses palliative care, he or she can expect “a barrage of criticism for allowing a patient to die of an illness that has a strong volitional component, especially if the patient is relatively young,” according to Dr.  Westmoreland and colleagues.

The authors suggest rigorous criteria are needed for sending AN patients for involuntary treatment. These could include cardiac arrhythmias,  severe hypoglycemia, severe blood chemistry abnormalities, acute psychiatric or ominous medical symptoms, suicidal thoughts, a body mass index less than 13 mg/kg2, or a poor response to prior interventions, and importantly, danger to self (Curr Opin Psychiatry. 2008;21:495).   However, the authors also point out that criteria do exist for deciding not to commit a patient with a severe life-threatening disorder. Also, there is no concrete list of criteria for admitting such patients.  For example, in their own state of Colorado, in order for treatment to begin over a patient’s objections, an individual must not only be mentally ill and incompetent to participate in a rational choice involving psychiatric care but it must also be proved that treatment is needed to prevent harm to others or the patient, or to prevent deterioration in mental health. And, most jurisdictions require that there are no less- intrusive treatment alternatives. In Colorado, involuntary tube feeding has been designated a special procedure and requires a separate court hearing.

According to the results of one study of two groups of AN patients treated voluntarily or on an involuntary basis, almost  half of those treated involuntarily (and who previously did not endorse needing admission) agreed in hindsight and after just 2 weeks of treatment that they had needed treatment (Am J Psychiatry. 2008; 164:108). Such findings should provide some encouragement and reassurance to clinicians considering involuntary treatment for people with AN.