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1.  Inpatient Cognitive Behavior Therapy for Adolescents with Anorexia Nervosa: Immediate and Longer-Term Effects 
Introduction: Inpatient treatment for anorexia nervosa is often successful in restoring body weight, but a high percentage of patients relapse following discharge. The aim of the present study was to establish the immediate and longer-term effects of a novel inpatient program for adolescents that was designed to produce enduring change.
Method: Twenty-seven consecutive patients with severe anorexia nervosa were admitted to a 20-week inpatient treatment program based on the enhanced cognitive behavior therapy (CBT-E). The patients were assessed before and after hospitalization, and 6 and 12 months later.
Results: Twenty-six patients (96%) completed the program. In these patients, there was a substantial improvement in weight, eating disorder features, and general psychopathology that was well maintained at 12-month follow-up.
Conclusion: These findings suggest that inpatient CBT-E is a promising approach to the treatment of adolescents with severe anorexia nervosa.
PMCID: PMC3921605  PMID: 24575055
anorexia nervosa; eating disorders; adolescents; cognitive behavior therapy; family therapy; treatment; hospitalization; relapse
2.  Psychosomatic syndromes and anorexia nervosa 
BMC Psychiatry  2013;13:14.
In spite of the role of some psychosomatic factors as alexithymia, mood intolerance, and somatization in both pathogenesis and maintenance of anorexia nervosa (AN), few studies have investigated the prevalence of psychosomatic syndromes in AN. The aim of this study was to use the Diagnostic Criteria for Psychosomatic Research (DCPR) to assess psychosomatic syndromes in AN and to evaluate if psychosomatic syndromes could identify subgroups of AN patients.
108 AN inpatients (76 AN restricting subtype, AN-R, and 32 AN binge-purging subtype, AN-BP) were consecutively recruited and psychosomatic syndromes were diagnosed with the Structured Interview for DCPR. Participants were asked to complete psychometric tests: Body Shape Questionnaire, Beck Depression Inventory, Eating Disorder Inventory–2, and Temperament and Character Inventory. Data were submitted to cluster analysis.
Illness denial (63%) and alexithymia (54.6%) resulted to be the most common syndromes in our sample. Cluster analysis identified three groups: moderate psychosomatic group (49%), somatization group (26%), and severe psychosomatic group (25%). The first group was mainly represented by AN-R patients reporting often only illness denial and alexithymia as DCPR syndromes. The second group showed more severe eating and depressive symptomatology and frequently DCPR syndromes of the somatization cluster. Thanatophobia DCPR syndrome was also represented in this group. The third group reported longer duration of illness and DCPR syndromes were highly represented; in particular, all patients were found to show the alexithymia DCPR syndrome.
These results highlight the need of a deep assessment of psychosomatic syndromes in AN. Psychosomatic syndromes correlated differently with both severity of eating symptomatology and duration of illness: therefore, DCPR could be effective to achieve tailored treatments.
PMCID: PMC3556145  PMID: 23302180
Anorexia nervosa; Eating disorders; Psychosomatic syndromes; Illness denial; Alexithymia
3.  Complement C3 serum levels in anorexia nervosa: a potential biomarker for the severity of disease? 
Anorexia nervosa carries the highest mortality rate of any psychiatric disorder. Even the most critically ill anorexic patients may present with normal 'standard' laboratory values, underscoring the need for a new sensitive biomarker. The complement cascade, a major component of innate immunity, represents a driving force in the pathophysiology of multiple inflammatory disorders. The role of complement in anorexia nervosa remains poorly understood. The present study was designed to evaluate the role of complement C3 levels, the extent of complement activation and of complement hemolytic activity in serum, as potential new biomarkers for the severity of anorexia nervosa.
Patients and methods
This was a prospective cohort study on 14 patients with severe anorexia nervosa, as defined by a body mass index (BMI) <14 kg/m2. Serum samples were obtained in a biweekly manner until hospital discharge. A total of 17 healthy subjects with normal BMI values served as controls. The serum levels of complement C3, C3a, C5a, sC5b-9, and of the 50% hemolytic complement activity (CH50) were quantified and correlated with the BMIs of patients and control subjects.
Serum C3 levels were significantly lower in patients with anorexia nervosa than in controls (median 3.7 (interquartile range (IQR) 2.5-4.9) vs 11.4 (IQR 8.9-13.7, P <0.001). In contrast, complement activation fragments and CH50 levels were not significantly different between the two groups. There was a strong correlation between index C3 levels and BMI (Spearman correlation coefficient = 0.71, P <0.001).
Complement C3 serum levels may represent a sensitive new biomarker for monitoring the severity of disease in anorexia nervosa. The finding from this preliminary pilot study will require further investigation in future prospective large-scale multicenter trials.
PMCID: PMC3110119  PMID: 21542928
4.  Long-term misuse of zopiclone in an alcohol dependent woman with a history of anorexia nervosa: a case report 
The Z-drugs, zaleplon, zopiclone and zolpidem, are short-acting hypnotics which act at the same receptor as the benzodiazepines, but seemingly without the potential for misuse and the development of dependence of the older benzodiazepines. However, with increased prescribing of Z-drugs, reports of misuse and possible dependence began to appear in the literature, particularly in people with a history of substance misuse and comorbid psychiatric illness. Here we report the case of a woman with a history of chronic zopiclone use and anorexia nervosa, admitted for alcohol detoxification.
Case presentation
A 31-year old Caucasian British woman with a history of long-term zopiclone use and anorexia nervosa was admitted as an inpatient for a ten-day alcohol detoxification. Her weekly (four days out of seven) intake of alcohol was 180 units and her daily intake of zopiclone, 30 mg. Apart from a short period five years ago, she had been taking zopiclone for 13 years at daily doses of up to 90 mg. She admitted to using 'on top' of her prescribed medication, purchasing extra tablets from friends or receiving them gratis from her partner. After detoxification from alcohol and zopiclone, she was prescribed diazepam which she found ineffectual and voiced her intention of returning to zopiclone on leaving the hospital.
Zopiclone is generally regarded as safer than benzodiazepines, however, this particular individual, who was using high doses of zopiclone over many years, may provide further evidence of a risk of dependency when this drug is prescribed for substance users with a comorbid psychiatric illness.
PMCID: PMC3014964  PMID: 21143957
5.  Chronic Anorexia Nervosa: Medical Mimic 
Western Journal of Medicine  1981;135(4):257-265.
While anorexia nervosa is typically construed as an acute, dramatic disorder of younger women, long-term follow-up studies indicate that morbidity is chronic or relapsing in 30 percent to 50 percent of cases and sometimes leads to death. In older patients or those with atypical clinical features or obscure complications, chronic starvation may mimic other diseases, and rigid adherence to current diagnostic criteria may impede recognition and appropriate treatment. Anorexia nervosa should be viewed as a spectrum of disorders, with varying courses and presentations, in order that clinicians in nonpsychiatric settings may be equipped to provide adequate care of patients with this complex psychosomatic disease.
PMCID: PMC1273165  PMID: 7342455
6.  Inpatient Cognitive Behaviour Therapy for Anorexia Nervosa: A Randomized Controlled Trial 
Psychotherapy and Psychosomatics  2013;82(6):390-398.
The aim of this study was to compare the immediate and longer-term effects of two cognitive behaviour therapy programmes for hospitalized patients with anorexia nervosa, one focused exclusively on the patients' eating disorder features and the other focused also on mood intolerance, clinical perfectionism, core low self-esteem or interpersonal difficulties. Both programmes were derived from enhanced cognitive behaviour therapy (CBT-E) for eating disorders.
Eighty consecutive patients with severe anorexia nervosa were randomized to the two inpatient CBT-E programmes, both of which involved 20 weeks of treatment (13 weeks as an inpatient and 7 as a day patient). The patients were then followed up over 12 months. The assessments were made blind to treatment condition.
Eighty-one percent of the eligible patients accepted inpatient CBT-E, of whom 90% completed the 20 weeks of treatment. The patients in both programmes showed significant improvements in weight, eating disorder and general psychopathology. Deterioration after discharge did occur but it was not marked and it was restricted to the first 6 months. There were no statistically significant differences between the effects of the two programmes.
These findings suggest that both versions of inpatient CBT-E are well accepted by these severely ill patients and might be a viable and promising treatment for severe anorexia nervosa. There appears to be no benefit from using the more complex form of the treatment.
PMCID: PMC3884188  PMID: 24060628
Anorexia nervosa; Body mass index; Cognitive behaviour therapy; Eating disorders, diagnosis, therapy; Female; Follow-up studies; Humans; Inpatient treatment; Relapse

7.  Axis-I comorbidity is linked to prospective instability of diagnoses within eating disorders 
BMC Psychiatry  2013;13:295.
Eating disorders (ED) are classified into Anorexia Nervosa, Bulimia Nervosa, and eating disorder not otherwise specified. Prospectively, the diagnostic instability within ED is high, but it is not clear which factors may account for this instability. So far, there is no evidence of whether psychiatric comorbidity may play a role in ED diagnostic crossover. We sought to determine possible influences of comorbidities of axis I and II on diagnostic crossover within ED.
Longitudinal data of 192 female patients were collected. All patients had a diagnosis of a current ED at study entry (baseline, T0). Diagnoses were re-established both 12 months (T1) and 30 months (T2) after T0. Comorbid psychiatric diagnoses were grouped into axis I and axis II according to DSM-IV.
Patients with instable ED diagnoses had lifetime axis-I comorbidity more frequently than patients with stable ED diagnoses (χ2 = 4.74, df = 1, p < 0.05). Post-hoc exploratory tests suggested that the effect was mainly driven by affective disorders like major depression. There was no difference for axis-II comorbidity between stable and instable diagnostic profiles.
Following previous reports of diagnostic crossover in ED, the present investigation points to an influence of a life-time psychiatric comorbidity, in particular of axis I, on follow-up diagnoses of ED. Comorbid affective disorders like major depression might facilitate a switching between clinical phenotypes. The understanding of mechanisms and causes of the symptoms fluctuation will be subject of future studies.
PMCID: PMC3875352  PMID: 24199632
Eating disorders; Anorexia Nervosa; Bulimia Nervosa; Comorbidity; Diagnostic instability; Affective disorder
8.  Irisin Levels are Not Affected by Physical Activity in Patients with Anorexia Nervosa 
Irisin was recently identified as muscle-derived hormone that increases energy expenditure. Studies in normal weight and obese subjects reported an increased irisin expression following physical activity, although inconsistent results were observed. Increased physical activity in a subgroup of patients with anorexia nervosa (AN) complicates the course of the disease. Since irisin could account for differences in clinical outcomes, we investigated irisin levels in anorexic patients with high and moderate physical activity to evaluate whether irisin differs with increasing physical activity. Hospitalized female anorexic patients (n = 39) were included. Plasma irisin measured by enzyme-linked immunosorbent assay and locomotor activity were assessed at the same time. Patients were separated into two groups (n = 19/group; median excluded): moderate and high activity (6331 ± 423 vs. 13743 ± 1047 steps/day, p < 0.001). The groups did not differ in body mass index (14.2 ± 0.4 vs. 15.0 ± 0.4 kg/m2), irisin levels (558.2 ± 26.1 vs. 524.9 ± 25.2 ng/ml), and body weight-adjusted resting energy expenditure (17.6 ± 0.3 vs. 18.0 ± 0.3 kcal/kg/day, p > 0.05), whereas body weight-adjusted total energy expenditure (46.0 ± 1.4 vs. 41.1 ± 1.1 kcal/kg/day), metabolic equivalents (METs, 1.9 ± 0.1 vs. 1.7 ± 0.1 METs/day), body weight-adjusted exercise activity thermogenesis (1.8 ± 0.5 vs. 0.6 ± 0.3 kcal/kg/day), duration of exercise (18.6 ± 4.7 vs. 6.2 ± 3.1 min/day), and body weight-adjusted non-exercise activity thermogenesis (21.6 ± 1.0 vs. 18.8 ± 0.8 kcal/kg/day) were higher in the high activity compared to the moderate activity group (p < 0.05). No correlations were observed between irisin and activity parameters in the whole sample (p > 0.05). In conclusion, the current data do not support the concept of irisin being induced by exercise, at least not under conditions of severely reduced body weight like AN.
PMCID: PMC3880939  PMID: 24432013
brown adipose tissue; energy expenditure; exercise; FNDC5; myokine; SenseWear™ armband
9.  Compliance and outcome in anorexia nervosa. 
Western Journal of Medicine  1990;153(2):133-139.
Anorexia nervosa is notoriously difficult to treat, but little is known regarding the relationship of compliance to treatment outcome. We investigated in 41 adolescents who fulfilled DSM-III-R criteria for anorexia nervosa, the relationship between the completion of a standard psychosocial treatment program, subtypes of anorexia nervosa, and outcome as determined by standardized measurements. These adolescents were observed for an average of 32.4 months. Overall, 29 patients (70%) improved considerably, but 10 (24%) were symptomatic, and 2 (5%) remained in poor condition. There were no deaths. Of the 41 patients, 14 (34%) completed our entire treatment program, 15 (37%) received major treatment and failed in the outpatient follow-up phase only, 7 (17%) dropped out of inpatient treatment before its completion, and 5 (12%) refused treatment in our system altogether. Of all the dropouts, 10 received no further treatment. One patient was admitted to hospital elsewhere but again dropped out in the outpatient phase of that program. Seven patients (17%) received further outpatient treatment only, and 9 (22%) received inpatient and outpatient care and seemingly completed their treatment. Treatment completion significantly affected the measures of global clinical functioning and specific psychopathologic features, but only for those patients who completed the initial program. Bulimic patients did considerably worse on follow-up and were less likely to complete treatment. Patients with restricted anorexia nervosa were more likely to complete treatment than those with a bulimic subtype (P = .03). Differential compliance rates in the two subtypes confound the effects of treatment completion and need to be controlled for in future studies. Depression was not associated with noncompliance but, if present, was associated with poor outcome on follow-up and abated in only a third of those in whom it was initially present.
PMCID: PMC1002496  PMID: 2219868
10.  Cognitive Flexibility and Clinical Severity in Eating Disorders 
PLoS ONE  2011;6(6):e20462.
The aim of this study was to explore cognitive flexibility in a large dataset of people with Eating Disorders and Healthy Controls (HC) and to see how patient characteristics (body mass index [BMI] and length of illness) are related to this thinking style.
A dataset was constructed from our previous studies using a conceptual shift test - the Brixton Spatial Anticipation Test. 601 participants were included, 215 patients with Anorexia Nervosa (AN) (96 inpatients; 119 outpatients), 69 patients with Bulimia Nervosa (BN), 29 Eating Disorder Not Otherwise Specified (EDNOS), 72 in long-term recovery from AN (Rec AN) and a comparison group of 216 HC.
The AN and EDNOS groups had significantly more errors than the other groups on the Brixton Test. In comparison to the HC group, the effect size decrement was large for AN patients receiving inpatient treatment and moderate for AN outpatients.
These findings confirm that patients with AN have poor cognitive flexibility. Severity of illness measured by length of illness does not fully explain the lack of flexibility and supports the trait nature of inflexibility in people with AN.
PMCID: PMC3115939  PMID: 21698277
Endocrine Practice  2008;14(8):1055-1063.
To describe the hormonal adaptations and alterations in anorexia nervosa.
We performed a PubMed search of the English-language literature related to the pathophysiology of the endocrine disorders observed in anorexia nervosa, and we describe a case to illustrate these findings.
Anorexia nervosa is a devastating disease with a variety of endocrine manifestations. The effects of starvation are extensive and negatively affect the pituitary gland, thyroid gland, adrenal glands, gonads, and bones. Appetite is modulated by the neuroendocrine system, and characteristic patterns of leptin and ghrelin concentrations have been observed in anorexia nervosa. A thorough understanding of refeeding syndrome is imperative to nutrition rehabilitation in these patients to avoid devastating consequences. Although most endocrinopathies associated with anorexia nervosa reverse with recovery, short stature, osteoporosis, and infertility may be long-lasting complications. We describe a 20-year-old woman who presented with end-stage anorexia nervosa whose clinical course reflects the numerous complications caused by this disease.
The effects of severe malnutrition and subsequent refeeding are extensive in anorexia nervosa. Nutrition rehabilitation is the most appropriate treatment for these patients; however, it must be done cautiously.
PMCID: PMC3278909  PMID: 19095609
12.  Successful Treatment of Anorexia Nervosa in a 10-year-old Boy with Risperidone Long-acting Injection 
Although the effectiveness of medication in the treatment of anorexia nervosa is uncertain, atypical antipsychotics such as olanzapine and risperidone have been used empirically for decades. we describe the case of a 10-year-old boy with anorexia nervosa in whom remarkable improvement was seen following the administration of risperidone or risperidone long-acting injection and deterioration when these agents were ceased. Because this is, to the best of our knowledge, the first report describing the usefulness of risperidone long-acting injection for adolescent anorexia nervosa.
PMCID: PMC4022768  PMID: 24851123
Anorexia nervosa; Eating disorders; Risperidone long-acting injection; Child
13.  The Impact of Intranasal Oxytocin on Attention to Social Emotional Stimuli in Patients with Anorexia Nervosa: A Double Blind within-Subject Cross-over Experiment 
PLoS ONE  2014;9(3):e90721.
Background and aim
Social factors may be of importance causally and act as maintenance factors in patients with anorexia nervosa. Oxytocin is a neuromodulatory hormone involved in social emotional processing associated with attentional processes. This study aimed to examine the impact of oxytocin on attentional processes to social faces representing anger, disgust, and happiness in patients with anorexia nervosa.
A double-blind, placebo-controlled within-subject crossover design was used. Intranasal oxytocin or placebo followed by a visual probe detection task with faces depicting anger, disgust, and happiness was administered to 64 female subjects: 31 patients with anorexia nervosa and 33 control students.
Attentional bias to the disgust stimuli was observed in both groups under the placebo condition. The attentional bias to disgust was reduced under the oxytocin condition (a moderate effect in the patient group). Avoidance of angry faces was observed in the patient group under the placebo condition and vigilance was observed in the healthy comparison group; both of these information processing responses were moderated by oxytocin producing an increase in vigilance in the patients. Happy/smiling faces did not elicit an attentional response in controls or the patients under either the placebo or oxytocin conditions.
Oxytocin attenuated attentional vigilance to disgust in patients with anorexia nervosa and healthy controls. On the other hand, oxytocin changed the response to angry faces from avoidance to vigilance in patients but reduced vigilance to anger in healthy controls. We conclude that patients with anorexia nervosa appear to use different strategies/circuits to emotionally process anger from their healthy counterparts.
PMCID: PMC3946210  PMID: 24603863
14.  Postprandial oxytocin secretion is associated with severity of anxiety and depressive symptoms in anorexia nervosa 
The Journal of clinical psychiatry  2013;74(5):e451-e457.
Anorexia nervosa, a psychiatric disorder characterized by self-induced starvation, is associated with endocrine dysfunction and comorbid anxiety and depression. Animal data suggest that oxytocin may have anxiolytic and antidepressant effects. We have reported increased postprandial oxytocin levels in women with active anorexia nervosa (AN), and decreased levels in weight-recovered women with anorexia nervosa (ANWR) compared to healthy controls (HC). A meal may represent a significant source of stress in patients with disordered eating. We therefore investigated the association between post-prandial oxytocin secretion and symptoms of anxiety and depression in anorexia nervosa.
We performed a cross-sectional study of 35 women (13 AN, 9 ANWR and 13 HC). Serum oxytocin and cortisol and plasma leptin levels were measured fasting and 30, 60, and 120min after a standardized mixed meal. The area under the curve (AUC), and for oxytocin, postprandial nadir and peak levels were determined. Anxiety and depressive symptoms were assessed using the Spielberger State-Trait Anxiety Inventory (STAI) and Beck Depression Inventory II (BDI-II).
In women with anorexia nervosa, oxytocin AUC and post-prandial nadir and peak levels were positively associated with STAI scores. Oxytocin AUC and nadir levels were positively associated with BDI-II scores. After controlling for cortisol AUC, most relationships remained significant. After controlling for leptin AUC, all of the relationships remained significant. Oxytocin secretion explained up to 51% of the variance in STAI trait and 24% of BDI-II scores.
Abnormal post-prandial oxytocin secretion in women with anorexia nervosa is associated with increased symptoms of anxiety and depression. This may represent an adaptive response of oxytocin secretion to food-related symptoms of anxiety and depression.
PMCID: PMC3731039  PMID: 23759466
Anorexia nervosa; oxytocin; anxiety; depression; cortisol; leptin
15.  Obsessive-Compulsive Disorder and Anorexia Nervosa in a High School Athlete: A Case Report 
Journal of Athletic Training  1999;34(4):375-378.
To describe the case of a basketball and track athlete who presented with both anorexia nervosa and obsessive- compulsive disorder (OCD).
OCD is a psychiatric condition known to appear with significant frequency among those with anorexia. Although treatable with drug and behavioral therapy, it must be specifically sought because some of its symptoms are similar to those of anorexia nervosa.
Differential Diagnosis:
Obsessive-compulsive disorder, anxiety disorder.
Behavioral therapy involves exposure to the obsessive fears without allowing the patient to ritualize. This is best used in combination with drugs that selectively block the reuptake of serotonin in the brain.
Anorexia nervosa is notoriously difficult to treat. In our patient, anorexic symptoms all but disappeared along with the OCD in a matter of weeks, once treatment of the OCD began. Lengthy treatment for anorexia alone had been unsuccessful.
OCD occurs frequently in patients with anorexia, and successful treatment requires that both conditions be specifically identified and managed. Athletic trainers may be the first to recognize key signs and symptoms of this illness; by referring the individual for psychiatric evaluation, they can be instrumental in helping the patient to obtain appropriate treatment.
PMCID: PMC1323350  PMID: 16558592
anxiety disorder; selective serotonin reuptake inhibitor; SSRI; obsessions; compulsions; eating disorder
16.  Decreases in blood perfusion of the anterior cingulate gyri in Anorexia Nervosa Restricters assessed by SPECT image analysis 
BMC Psychiatry  2001;1:2.
It is possible that psychopathological differences exist between the restricting and bulimic forms of anorexia nervosa. We investigated localized differences of brain blood flow of anorexia nervosa patients using SPECT image analysis with statistic parametric mapping (SPM) in an attempt to link brain blood flow patterns to neurophysiologic characteristics.
The subjects enrolled in this study included the following three groups: pure restrictor anorexics (AN-R), anorexic bulimics (AN-BP), and healthy volunteers (HV). All images were transformed into the standard anatomical space of the stereotactic brain atlas, then smoothed. After statistical analysis of each brain image, the relationships among images were evaluated.
SPM analysis of the SPECT images revealed that the blood flow of frontal area mainly containing bilateral anterior cingulate gyri (ACC) was significantly decreased in the AN-R group compared to the AN-BP and HV groups.
These findings suggest that some localized functions ofthe ACCare possibly relevant to the psychopathological aspects of AN-R.
PMCID: PMC32312  PMID: 11407997
17.  Factors Associated With Recovery from Anorexia Nervosa 
Journal of psychiatric research  2013;47(7):972-979.
Previous studies of prognostic factors of anorexia nervosa (AN) course and recovery have followed clinical populations after treatment discharge. This retrospective study examined the association between prognostic factors—eating disorder features, personality traits, and psychiatric comorbidity—and likelihood of recovery in a large sample of women with AN participating in a multi-site genetic study. The study included 680 women with AN. Recovery was defined as the offset of AN symptoms if the participant experienced at least one year without any eating disorder symptoms of low weight, dieting, binge eating, and inappropriate compensatory behaviors. Participants completed a structured interview about eating disorders features, psychiatric comorbidity, and self-report measures of personality. Survival analysis was applied to model time to recovery from AN. Cox regression models were used to fit associations between predictors and the probability of recovery. In the final model, likelihood of recovery was significantly predicted by the following prognostic factors: vomiting, impulsivity, and trait anxiety. Self-induced vomiting and greater trait anxiety were negative prognostic factors and predicted lower likelihood of recovery. Greater impulsivity was a positive prognostic factor and predicted greater likelihood of recovery. There was a significant interaction between impulsivity and time; the association between impulsivity and likelihood of recovery decreased as duration of AN increased. The anxiolytic function of some AN behaviors may impede recovery for individuals with greater trait anxiety.
PMCID: PMC3682792  PMID: 23535032
Eating disorders; anorexia nervosa; recovery; prognostic factors; personality; comorbidity
18.  Anorexia nervosa: treatment expectations – a qualitative study 
Anorexia nervosa is a serious illness with a high mortality rate, a poor outcome, and no empirically supported treatment of choice for adults. Patients with anorexia nervosa strive for thinness in order to obtain self-control and are ambivalent toward change and toward treatment. In order to achieve a greater understanding of patients’ own understanding of their situation, the aim of this study was to examine the expectations of potential anorexic patients seeking treatment at a specialized eating-disorder unit.
A qualitative study design was used. It comprised 15 women between 18 and 25 years of age waiting to be assessed before treatment. The initial question was, “What do you expect, now that you are on the waiting list for a specialized eating-disorder unit?” A content analysis was used, and the text was coded, categorized according to its content, and further interpreted into a theme.
From the results emerged three main categories of what participants expected: “treatment content,” “treatment professionals,” and “treatment focus.” The overall theme, “receiving adequate therapy in a collaborative therapeutic relationship and recovering,” described how the participants perceived that their expectations could be fulfilled.
Patients’ expectations concerning distorted thoughts, eating behaviors, a normal, healthy life, and meeting with a professional with knowledge and experience of eating disorders should be discussed before treatment starts. In the process of the therapeutic relationship, it is essential to continually address patients’ motivations, in order to understand their personal motives behind what drives their expectations and their desire to recover.
PMCID: PMC3413044  PMID: 22888259
anorexia nervosa; expectations; treatment; qualitative research
19.  The Prevalence and Correlates of Eating Disorders in the National Comorbidity Survey Replication 
Biological psychiatry  2006;61(3):348-358.
Little population-based data exist on the prevalence or correlates of eating disorders.
Prevalence and correlates of eating disorders from the National Comorbidity Replication, a nationally representative face-to-face household survey (n _ 9282), conducted in 2001–2003, were assessed using the WHO Composite International Diagnostic Interview.
Lifetime prevalence estimates of DSM-IV anorexia nervosa, bulimia nervosa, and binge eating disorder are .9%, 1.5%, and 3.5% among women, and .3% .5%, and 2.0% among men. Survival analysis based on retrospective age-of-onset reports suggests that risk of bulimia nervosa and binge eating disorder increased with successive birth cohorts. All 3 disorders are significantly comorbid with many other DSM-IV disorders. Lifetime anorexia nervosa is significantly associated with low current weight (body-mass index18.5), whereas lifetime binge eating disorder is associated with current severe obesity (body-mass index < _ 40). Although most respondents with 12-month bulimia nervosa and binge eating disorder report some role impairment (data unavailable for anorexia nervosa since no respondents met criteria for 12-month prevalence), only a minority of cases ever sought treatment.
Eating disorders, although relatively uncommon, represent a public health concern because they are frequently associated with other psychopathology and role impairment, and are frequently under-treated.
PMCID: PMC1892232  PMID: 16815322
Anorexia nervosa; binge eating disorder; bulimia nervosa; eating disorders; epidemiology; national comorbidity survey replication (NCS-R)
20.  Resting tachycardia, a warning sign in anorexia nervosa: case report 
Among psychiatric disorders, anorexia nervosa has the highest mortality rate. During an exacerbation of this illness, patients frequently present with nonspecific symptoms. Upon hospitalization, anorexia nervosa patients are often markedly bradycardic, which may be an adaptive response to progressive weight loss and negative energy balance. When anorexia nervosa patients manifest tachycardia, even heart rates in the 80–90 bpm range, a supervening acute illness should be suspected.
Case presentation
A 52-year old woman with longstanding anorexia nervosa was hospitalized due to progressive leg pain, weakness, and fatigue accompanied by marked weight loss. On physical examination she was cachectic but in no apparent distress. She had fine lanugo-type hair over her face and arms with an erythematous rash noted on her palms and left lower extremity. Her blood pressure was 96/50 mm Hg and resting heart rate was 106 bpm though she appeared euvolemic. Laboratory tests revealed anemia, mild leukocytosis, and hypoalbuminemia. She was initially treated with enteral feedings for an exacerbation of anorexia nervosa, but increasing leukocytosis without fever and worsening left leg pain prompted the diagnosis of an indolent left lower extremity cellulitis. With antibiotic therapy her heart rate decreased to 45 bpm despite minimal restoration of body weight.
Bradycardia is a characteristic feature of anorexia nervosa particularly with significant weight loss. When anorexia nervosa patients present with nonspecific symptoms, resting tachycardia should prompt a search for potentially life-threatening conditions.
PMCID: PMC503388  PMID: 15257758
anorexia nervosa; bradycardia; tachycardia; malnutrition
21.  Two diagnoses become one? Rare case report of anorexia nervosa and Cushing’s syndrome 
Hypothalamic-pituitary-adrenal axis impairment in anorexia nervosa is marked by hypercortisolemia, and psychiatric disorders occur in the majority of patients with Cushing’s syndrome. Here we report a patient diagnosed with anorexia nervosa who also developed Cushing’s syndrome. A 26-year-old female had been treated for anorexia nervosa since she was 17 years old, and also developed depression and paranoid schizophrenia. She was admitted to the Department of Endocrinology, Metabolism, and Internal Medicine with a preliminary diagnosis of Cushing’s syndrome. Computed tomography revealed a 27 mm left adrenal tumor, and she underwent laparoscopic adrenalectomy. She was admitted to hospital 6 months after this procedure, at which time she did not report any eating or mood disorder. This is a rare case report of a patient with anorexia nervosa in whom Cushing’s syndrome was subsequently diagnosed. Diagnostic difficulties were caused by the signs and symptoms presenting in the course of both disorders, ie, hypercortisolemia, osteoporosis, secondary amenorrhea, striae, hypokalemia, muscle weakness, and depression.
PMCID: PMC3621711  PMID: 23579693
anorexia nervosa; Cushing’s syndrome; adrenalectomy; osteoporosis
22.  Increased Physical Activity Not Decreased Energy Intake Is Associated with Inpatient Medical Treatment for Anorexia Nervosa in Adolescent Females 
PLoS ONE  2013;8(4):e61559.
There is a dearth of data regarding changes in dietary intake and physical activity over time that lead to inpatient medical treatment for anorexia nervosa (AN). Without such data, more effective nutritional therapies for patients cannot be devised. This study was undertaken to describe changes in diet and physical activity that precede inpatient medical hospitalization for AN in female adolescents. This data can be used to understand factors contributing to medical instability in AN, and may advance rodent models of AN to investigate novel weight restoration strategies. It was hypothesized that hospitalization for AN would be associated with progressive energy restriction and increased physical activity over time. 20 females, 11–19 years (14.3±1.8 years), with restricting type AN, completed retrospective, self-report questionnaires to assess dietary intake and physical activity over the 6 month period prior to inpatient admission (food frequency questionnaire, Pediatric physical activity recall) and 1 week prior (24 hour food recall, modifiable activity questionnaire). Physical activity increased acutely prior to inpatient admission without any change in energy or macronutrient intake. However, there were significant changes in reported micronutrient intake causing inadequate intake of Vitamin A, Vitamin D, and pantothenic acid at 1 week versus high, potentially harmful, intake of Vitamin A over 6 months prior to admission. Subject report of significantly increased physical activity, not decreased energy intake, were associated with medical hospitalization for AN. Physical activity and Vitamin A and D intake should be carefully monitored following initial AN diagnosis, as markers of disease progression as to potentially minimize the risk of medical instability.
PMCID: PMC3630220  PMID: 23637854
23.  Remission of anorexia nervosa after thyroidectomy: A report of two cases with Graves' disease and anorexia nervosa 
Thyroid Research  2011;4:17.
We report two patients with anorexia nervosa and Graves' disease who received subtotal thyroidectomy for Graves' disease and concomitantly experienced remission from anorexia nervosa. Both were young women (aged 20 and 26) at the time of surgery. Both had well controlled thyroid function and eating behavior at the time of surgery. Both were followed for over five years without relapse of anorexia nervosa or hyperthyroidism. These cases suggest the existence of an endocrine factor originating from the thyroid gland that is involved in the pathogenesis of anorexia nervosa. Since patients of thyroidectomy can remain in good health with supplement of thyroxine alone, it can be hypothesized that this anorexigenic endocrine factor is an evolutionary relic not necessary for the normal function of humans and does not have physiological effects unless secreted beyond normal levels. Given that, it implies the existence of a creature in the animal kingdom for which such an anorexigenic hormone is essential for survival. Migrating birds eat beyond their caloric expenditure before migration and become anorexic for the duration of their flight. It is also known that their thyroid function is elevated during migration. The normal physiology of migration is a complex mechanism involving the hypothalamic, pituitary, thyroid, adrenal and reproductive hormones. The mechanism of disease, however, can be simpler. A review of the literature is presented that suggest a heretofore unreported thyroid hormone, which is involved in the regulation of migration behavior, may be the responsible factor behind anorexia nervosa.
PMCID: PMC3253671  PMID: 22128818
thyroid; anorexia nervosa; thyroidectomy; avian migration
24.  Tandospirone, a 5-HT1A partial agonist is effective in treating anorexia nervosa: a case series 
This case report details the therapeutic effects of tandospirone on two patients with anorexia nervosa, one with the restricting subtype (ANR), and another with the binge-eating/purging subtype (ANBP). A 22-year-old female patient with ANR and a 23-year-old female patient with ANBP were treated successfully with the 5-HT1A partial agonist tandospirone. After treatment, not only did both patients gain weight, they also showed improved scores on the Eating Disorder Examination Questionnaire. In addition, a 6-month follow-up showed maintenance of these effects. In this disorder, tandospirone may be an effective drug for long-term use with good patient compliance.
PMCID: PMC3606595  PMID: 23497393
Anorexia nervosa; Pharmacotherapy; Treatment; Serotonin 1A receptor; Tandospirone
25.  Predictors of the resumption of menses in adolescent anorexia nervosa 
BMC Psychiatry  2013;13:308.
The resumption of menses is an important indicator of recovery in anorexia nervosa (AN). Patients with early-onset AN are at particularly great risk of suffering from the long-term physical and psychological consequences of persistent gonadal dysfunction. However, the clinical variables that predict the recovery of menstrual function during weight gain in AN remain poorly understood. The aim of this study was to investigate the impact of several clinical parameters on the resumption of menses in first-onset adolescent AN in a large, well-characterized, homogenous sample that was followed-up for 12 months.
A total of 172 female adolescent patients with first-onset AN according to DSM-IV criteria were recruited for inclusion in a randomized, multi-center, German clinical trial. Menstrual status and clinical variables (i.e., premorbid body mass index (BMI), age at onset, duration of illness, duration of hospital treatment, achievement of target weight at discharge, and BMI) were assessed at the time of admission to or discharge from hospital treatment and at a 12-month follow-up. Based on German reference data, we calculated the percentage of expected body weight (%EBW), BMI percentile, and BMI standard deviation score (BMI-SDS) for all time points to investigate the relationship between different weight measurements and resumption of menses.
Forty-seven percent of the patients spontaneously began menstruating during the follow-up period. %EBW at the 12-month follow-up was strongly correlated with the resumption of menses. The absence of menarche before admission, a higher premorbid BMI, discharge below target weight, and a longer duration of hospital treatment were the most relevant prognostic factors for continued amenorrhea.
The recovery of menstrual function in adolescent patients with AN should be a major treatment goal to prevent severe long-term physical and psychological sequelae. Patients with premenarchal onset of AN are at particular risk for protracted amenorrhea despite weight rehabilitation. Reaching and maintaining a target weight between the 15th and 20th BMI percentile is favorable for the resumption of menses within 12 months. Whether patients with a higher premorbid BMI may benefit from a higher target weight needs to be investigated in further studies.
PMCID: PMC3832684  PMID: 24238469
Resumption of menses; Adolescence anorexia nervosa; Target weight; Menstrual recovery; Outcome; Body mass index; Menarche; Amenorrhea

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